Bilingual RN Nurse Navigator (Remote)

Summary of Position:

The RN Nurse Navigator for AOC’s Health Home Services team, will be directly 
supporting AOC’s Star and Star Kids clients. In collaboration with other members of the healthcare team, the RN Service Coordinator is responsible for organizing, coordinating, and providing care coordination and care management services to clients who are receiving private duty nursing services (PDN) from Angels of Care. The RN Service Coordinator is responsible for assessing and coordinating client care across the continuum, utilizing accepted criteria and guidelines to manage Medicaid services and community resources. This position will function as a clinician, service coordinator, and educator to achieve optimal clinical and quality outcomes by effectively managing care and resources to improve the client experience for our families.

Pay Range : $75,000-$78,000

Essential Duties and Responsibilities (Other duties may be assigned): 

• Work collaboratively with patients, families, physicians and AOC staff to ensure high quality care for PDN clients. 
• Work with members of the client’s care team to better coordinate services and reduce burden on 
families. 

• Coordinate with hospitals and Managed Care Organizations (MCO) during hospital admissions and hospital discharge planning to ensure all referrals for services are in place.

• Assist with scheduling follow-up physician appointments for clients as needed and provide routine 
check-ins to ensure client/family is attending physician appointments.

• Communicate client needs with AOC teams including Triage team, Intensive Case Management Team, and Clinical Care Managers (CCM’s) on all aspects of client’s care needs.

• Provide frequent and ongoing communication with the client and family to identify needs and escalate to the appropriate care teams.

• Researches, evaluates, and recommends resources to meet medical and non-medical needs of clients and families. 

• Collaborates, refers, and communicates across all programs to ensure appropriate coordination of 
services.

• Act as the patient's advocate

• Maintain the patient's comprehensive clinical record through detailed documentation in the EMR and Health Home Hub

• Manage a caseload of clients who have been identified for health home services

• Develop trust and build rapport with a AOC clients/families

• Develop relationships with the care coordination teams, physicians, and clinic staff 

• Maintain a courteous and helpful manner when working with patients, physicians, and associates

• Assists client/families with self-management through education, visits and telephonic engagement; 
encourages and supports patient adherence to their care plans.

• Review patient non-compliance issues and conduct outreach to close them

• Participate in special projects and perform other duties as assigned by supervisor.

• May be required to travel to client homes to assess the client and their home environment. 

Supervisory Responsibilities: None

Performance Responsibilities: The following listing applies to every employee. All employees of the organization: 

• Exercise necessary cost control measures. 

• Maintain positive internal and external customer service relationships. 

• Demonstrate effective leadership skills. 

• Demonstrate effective communication skills by conveying necessary information accurately,
listening effectively and asking questions when clarification is needed. 

• Be depended upon to plan and organize work effectively and ensure its completion. 

• Meet all productivity requirements. 

• Demonstrate team behavior and must be willing to promote a team-oriented environment. 

• Represent the organization professionally at all times. 

• Demonstrate initiative

• Continually improve processes and relationships. 

Qualifications/Requirements:

• License: Registered Nurse 

• Minimum of 2 years Case Management experience in home health, managed care, or hospital case management, pediatric case management experience preferred 

• Minimum of 2 years of clinical experience in pediatric ambulatory care, inpatient setting, or home care.
 
Abilities, Skills, and Knowledge:

• Knowledge of case management, resource, and utilization management for Star Kids population

• Skilled in case management.

• Excellent verbal and written communication skills required.

• Ability to monitor, assess and record patient progress against a plan of care.

• Ability to facilitate pat