Care Navigator will be part of a multi- disciplinary team. Care Navigator requires independent decision making skills to effectively work with program participants using the triple aim model to reduce systems fragmentation with a focus on chronic condition management and high risk for readmission. Demonstrate the ability to integrate the bio-psychosocial (medical, behavior health, and social) approach into a comprehensive participant care planning process. An ability to work collaboratively with community and health care partners in planning wrap around services. Care Navigators will be responsible to:
- Provide health education and chronic disease management services to target populations.
- Teach classes on a variety of topics and for different audiences.
- Participating in community screenings and education events.
- An ability to take the information from all assessments to establish a plan of care that will result in the participants increased engagement in their health care,
- Bridge communication and chronic disease management between participants and providers
- Ensure medication access, coordination with providers and participant education
- Linkage to social supports necessary to manage the participant’s health care needs.
- Ensuring primary care provider directs clinical care models and clinical health navigator communicates relevant assessments and outcomes.
- Participates in care planning conferences.
- Complete and timely documentation, utilizing identified electronic record software.
- Identification of high risk participants in the acute care setting to ensure successful transition to next level of care
- Assist and empower participants to engage in self- management of chronic diseases by establishing relationships, home visits, extensive follow up, and providing resources as needed.
- Identification, management, and compilation of data metrics to measure impact.
- Ensure the use of evidence based, health literate educational materials and videos.
- Participate in staff and department planning meetings
- Participate in community or hospital committees as assigned
- Participate in department audit practices
- All interactions require an exemplary level of core customer service skills and competency
- Will be required to transport participants to healthcare appointments, as needed, utilizing TCCN departmental vehicle
All other duties as assigned
- 5 or more years’ experience as a clinical RN required or 5 years total related experience
- Prior experience in community health education or public health preferred.
- Prior experience as a Certified Diabetes Educator or Health Educator preferredEducation:
- Associate of Science in Nursing required
- Bachelor of Science in Nursing preferredLicense/Certification:
- American Heart Association Healthcare provider course with Basic Life Support (BLS) certification required to be initially completed with the GHS Staff Development Office within 30 calendar days of hire date (exceptions to obtain certification from a provider other than the GHS Staff Development Office are approved by Staff development on a case by case basis). BLS Recertification is required every two years.
- Current RN licensure in good standing with South Carolina Board of nursing required.Knowledge/Skill:
- Ability to work independently, adjust priorities often and establish rapport quickly.
- Demonstrated experience in diplomacy and ability to contribute to team goal setting and program development
- Proficient PC skills and experience of Windows and Microsoft office programs required.
- Proficient skills and experience in providing community vaccinations.
- Proficient skills and experience in clinical areas of technique within scope of practiceOther:
- Personal transportation required to conduct services, home visits, and transport materials and supplies to service location throughout the region.
- Valid SC driver’s license in good standing.Physical Requirements: Light-Medium Physical Agility Test Rating Required (PAT)
- While performing the duties of this job, the employee is frequently (activity or condition exists from 1/3 to 2/3 of the time) required to stand, sit, and walk; frequently to use hands, fingers; and frequently to talk or hear. The employee must exert 15 to 20 pounds of force occasionally (activity or condition exists up to 1/3 of the time), and/or 5 to 10 pounds of force frequently, and/or greater than negligible up to 5 pounds of force constantly to move objects. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job and will be tested by a post offer PAT.