Clinical Population Nurse Navigator (Onsite)

Job Description

Job Description

Job Description

The Clinical Population Health Care Coordinator serves as a patient advocate and liaison within the healthcare team, ensuring patients receive coordinated, efficient, and compassionate care. This role focuses on proactive patient outreach, timely care coordination, and patient/provider support to reduce hospital admissions, improve health outcomes, and ensure smooth transitions of care across settings.

Candidate must possess leadership qualities, be highly organized, self-motivated, able to work well with others and confident with EMR /computers/ data. Great benefits include health insurance, PTO, Paid Holidays, 401K, and more.

Clinical certifications: RN, LPN, APRN or PA license required.

Responsibilities:

Patient Engagement and Post-Discharge Support:

• Serve as the primary contact for patients requiring additional care coordination and navigation services.
• Educate patients and families about care plans, procedures, and available community resources.

Care Coordination:

• Foster and maintain relationships with local hospitals and ED staff to support ACO initiatives.
• Collaborate with hospital leadership, physicians, case managers, and ED staff on ACO initiatives and proper coordination of transitional care management and post-discharge care planning between multiple levels of care and interdisciplinary teams.
• Educate physicians, hospitals, and ED staff on data that pertains to ACO hospitalists and ACO patients.
• Facilitates care for high-risk members utilizing appropriate physician services (primary / specialist), care transitions and coordination of community support services.
• Utilize tools and resources to manage discharge alerts, monitor care transitions, and document all patient outreach and outcomes.
• Monitor and follow up on patient care plans, ensuring compliance and addressing any barriers.

Clinical Initiatives:

• Develop, implement, and evaluate clinical initiatives based on evidence-based guidelines to improve patient care.
• Develop, implement, and evaluate clinical initiatives based on evidence-based guidelines to improve patient care.
• Monitor outcomes and analyze data to measure the effectiveness of clinical initiatives.
• Work collaboratively with providers, staff and other health care professionals utilizing the latest technology to provide improved quality of care while reducing unnecessary tests, procedures, and overall costs.
• Educate ACO providers and staff on ACO data and guidelines.
• Develop strategies and tools to enhance accuracy, efficiency, and engagement of communication with physician members and office staff.
• Develop a team approach by working collaboratively with the primary care provider and other members of the healthcare team to ensure coordination of services.
• Provide on-site consultation, training and education to primary care providers and office staff.

Patient Advocacy:

• Advocate for patient needs within the healthcare system, addressing any gaps in care.
• Promote patient understanding and self-management of their health conditions.
• Collaborate with providers to identify and escalate complex or high-risk patients requiring additional support or interventions.

Qualifications / Experience:

• RN, LPN, APRN or PA license required.
• 2+ years’ experience in a healthcare setting.
• Knowledge of healthcare delivery systems in the out-patient office, hospital, ED, or post-acute settings.
• Strong organizational, leadership, project management and communication skills.
• Ability to work independently and as part of a multidisciplinary team
• Proficiency in EMR and Microsoft Office.
• Advanced skills with Spreadsheets / Report Writing / PowerPoint / Word/ Excel.
• Some after-hours responsibility.
• Unrestricted driver's license.

Competencies: To perform the job successfully, an individual should demonstrate the following competencies:

• Software: MS Office (Word, Excel, PowerPoint, etc.), EHR systems, SQL, online portals, population health database
• Organization/Planning Skills
• Problem Solving/Innovative
• Autonomous/Independent
• Knowledge of medical terminology
• Systems/Workflows/General IT
• Detail Oriented
• Dependable/Adaptable/Flexible
• Assertive/Reliable
• High stress tolerance
• Abide by all HIPPA, Confidentiality and Privacy laws
• Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; responds well to questions.
• Safety and Security - Uses equipment and materials properly.
• Attendance/Punctuality - Is consistently at work and on time.
• Knowledge of legal and ethical consideration related to patient information.

Physical Demands:

While performing the duties of this Job, the employee will have a combination of standing, sitting, bending, and reaching. May work at a computer monitor for prolonged periods. The employee may lift and/or move up to 10 pounds.

This position offers an opportunity to make a meaningful impact on patients' lives by providing essential support during critical transitions in their healthcare journey.

Job Type: Full-time

Pay: $70,000-$90,000 per year