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

Job Summary

Working within an interdisciplinary care integration team (CIT), the Care Navigator – Registered Nurse is responsible for proactively engaging patients and implementing targeted interventions to address whole person health and increased access to care. The Care Navigator – Registered Nurse will provide guidance and oversight of care coordination efforts to other members of the team, and manage 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 care or case management work with transitions of care and high-risk patient management programs in partnership with PCP care team members including community health workers, pharmacists, and behavioral health specialists.

Duties and Responsibilities

• Conduct Transitions of Care Management for a subset of the patient population, including hospital, obs, and post-acute care 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 support across the interdisciplinary team

• This may include and 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 CIT Team Meetings when indicated
• Assess patient’s family and caregiver system, and conduct family meetings with patient and family when needed
• Participate in creation and facilitation of team training content
• Participate in and lead CIT 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
• Perform all other duties and responsibilities as required

Required Qualifications

• Registered Nurse (RN license)
• Bilingual in English and Spanish or Creole with the ability to speak, read and write in both languages without limitations or assistance
• Minimum of 4 years of experience working in health care services and navigating community-based resources
• Experience working in care/case management

Preferred Qualifications

• Prior value-based care experience and working with complex Senior populations
• Experience working effectively within interdisciplinary teams

Skills/Abilities/Competencies Required

• Advanced clinical acumen
• Ability to multi-task in a fast-paced work environment
• Flexibility to fluidly transition and adjust in an evolving role
• Excellent organizational skills
• Advanced oral and written communication skills
• Strong interpersonal and relationship building skills
• Compassion and desire to advocate for patient needs
• Critical thinking and problem-solving capabilities

Working Conditions 

This role has a mobile presence and requires regular onsite engagement with the care team to assigned clinics to see patients in person and collaborate with care team members.

Workstyle: Hybrid - Combination in-clinic and working remotely/virtually.

Location: Must reside in designated market area, Miami-Dade County

Hours: Must be able to work a 40-hour work week, Monday through Friday 8:00 AM to 5:00 PM, incremental time may be requested