Become a part of our caring community and help us put health first
 

Working within an interdisciplinary care team, the Care Navigator is responsible for proactively engaging patients identified as high-risk and implementing targeted interventions to address social needs and increase access to care.  The Care Navigator will provide guidance and oversight of care coordination efforts to other members of the team, and handle clinical escalations as indicated. 



This role requires an understanding of how socio-economic stressors can impact ability to engage in healthcare and subsequent health outcomes.  Experience will ideally include prior work with patients with behavioral health diagnoses, as well as in navigating local community-based resources and benefit applications. 



This role has a mobile presence, involving travel to patients’ homes, treatment facilities and community-based settings, and assigned clinics to facilitate and foster connections.

Major Duties and Responsibilities

• Conduct Transitions of Care Management for a subset of the patient population, including ER and hospital follow ups
• Provide triage guidance and supportive consultation to other team members, handling escalated complex cases
• Develop care plans leveraging 5Ms Geriatric best practice framework
• Develop a wholistic view of patient needs related to Social Determinants of Health
• Identify existing barriers to engagement with necessary resources and supports
• Provide education around maintenance of chronic health conditions, as well as available options for behavioral care and social support
• Serve as liaison between the patient and the direct care providers, assisting in navigating both internal and external systems
• Initiate care planning and subsequent action steps for high-risk members, coordinating with interdisciplinary team
• Supporting patients’ self-determination, motivate patients to meet the health goals they have identified
• Refer patient to necessary services and supports
  • This field may include but is not limited to: assistance with transportation, food insecurity, navigation of and application for benefits including, Medicaid, HCBS, working to reduce costs associated with prescription medications, organizing schedules of follow up appointments, alleviating social isolation
• Lead Interdisciplinary Team Meetings when indicated
• Assess patient’s family system, and conduct family meetings with patient and family when needed
• Participate in creation and facilitation of team training content
• Conduct group psychoeducation and support groups within the Center
• Perform all other duties and responsibilities as required
• Participate in and lead interdisciplinary review of and coordination around complex patients
• Maintain patient confidentiality in accordance with HIPAA
• Document patient encounters in medical record system in a timely manner
• Follow general policies related to fire safety, infection control and attendance

 

Use your skills to make an impact
 

Required Qualifications

• Registered Nurse with 2 years of experience of in home case/care management
• Experience working with the adult population
• Knowledge of community health and social service agencies and additional community resources
• Ability to travel to member's residence within 30 to 40 miles
• Exceptional communication and interpersonal skills with the ability to quickly build rapport
• Ability to work with minimal supervision within the role and scope
• Ability to use a variety of electronic information applications/software programs including electronic medical records
• Intermediate to Advanced computer skills and experience with Microsoft Word, Outlook, and Excel
• Excellent keyboard and web navigation skills
• Ability to work a full-time (40 hours minimum) flexible work schedule
• This role is a part of Humana's Driver Safety program and therefore requires and individual to have a valid state driver's license and proof of personal vehicle liability insurance with at least 100,000/300,000/100,00 limits.
• Must have a separate room with a locked door that can be used as a home office to ensure continuous privacy while you work
• Must have accessibility to high speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana At Home systems if 5Mx1M
• This role is considered patient facing and is part of Humana At Home's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
• Valid driver's license, car insurance,