Endocrinology Nurse Care Navigator

About Our Company

We're a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care.

Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients' homes and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD, and Starling Physicians.

When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all.

We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care.

Job Description

Position Summary:

The Endocrinology Nurse Care Navigator serves as the liaison to a dynamic interdisciplinary team that consists of Endocrinology Physicians and APPs, Primary Care Physicians and APPs, Nutritionists, Social Workers, Endocrinology Nurses, Pharmacists, Laboratory Personnel, and Care Coordination teams.

The Endocrinology Nurse Care Navigator enrolls identified patients in the Diabetes Program and collaborates with the Endocrinology Providers to develop and adjust patient enrollee care plans as needed.

She/He, assisted by the endocrinology office staff (nurses, medical assistants, and patient service representatives), identifies all patient barriers and/or gaps in care for the identified diabetic patient population and performs the necessary outreach, which can include, but is not limited to providing appropriate patient education, obtaining referrals, and scheduling patient appointments.

Essential Job functions:

• Works with interdisciplinary care team to facilitate seamless patient engagement and transitions across the continuum of care.
• Learns and understands the overall Care Coordination process and goals and uses this information to identify and address patient barriers to care and gaps in care.
• Establishes professional relationship with patient's primary care physician. If the patient does not have a primary care physician, the patient will be referred to a Summit Health provider for primary care.
• Determines and completes appropriate referrals. Serves as a liaison to providers, patients, and families for coordination of services.
• Collaborates with providers and other healthcare team members to facilitate coordination and transitions of care across the healthcare continuum to optimize clinical and financial outcomes.
• Documents appropriately in the electronic health record and any required patient tracking documents. Employs appropriate and timely use of tasking in the EHR. Maintains accurate and timely documentation. Ensures documentation meets current standards and policies.
• Participates in regular team meetings and patient review activities. Participates in departmental and organizational committees, as applicable.
• Participates in the development of Diabetes Program protocols and workflows.
• Develops relationships across broad organizational lines.
• Performs all care coordination/navigation activities across the continuum of care while adhering to the core values of patient confidentiality, privacy, safety, advocacy, and adhering to ethical, legal, and accreditation/regulatory standards.
• Delivers care coordination services within the scope of licensure in accordance with Summit Health policy.
• Assumes accountability to changing patient and/or organizational priorities. Ability and willingness to self-motivate, to prioritize and change processes to improve effectiveness and efficiency. Adapts to changing patient or organizational priorities.
• Assumes accountability for the quality of care.
• Ability to manage conflict, stress, and multiple simultaneous work demands in an effective and professional manner.
• Continually seeks new knowledge and learning regarding diabetes and chronic disease management, social determinants of health, and coordination of care.
• Other duties as assigned.

General Job functions:

Coordination of Care:

• Performs telephonic outreach to patients monthly, or more frequently as needed, following program enrollment, and assures that the appropriate follow up visits are scheduled.
• Performs comprehensive medication reconciliation quarterly and during telephonic outreach when changes are identified.
• Reinforcing and reviewing plan of care, patient education, and the prevention of unnecessary emergency room visits and hospital admissions.

Quality Improvement Initiatives:

• Participates in ongoing QA/QI initiatives to improve performance and patient outcomes.
• Demonstrates ability to compile patient data and prepare outcome analysis.
• Serves as a resource for all current and future quality improvement initiatives within the Endocrinology Department.

Competency, Training and Education:

• Demonstrates knowledge of Care Coordination and Transitions of Care requirements and standards.
• Ability to implement the workflows that are specific to the Diabetes Program
• Demonstrates the ability to effectively communicate and collaborate with care team members.
• Communicates effectively with patients to engage them in Coordination of Care outreach.
• Maintains core proficiencies /competencies as defined by the Endocrinology Department.
• Self-motivation, focus, ability to work independently with good time and task management.
• Willingness to establish effective working relationships with internal and external customers.
• Maintains a good working relationship within the department and with other departments.
• Ability to work well independently, while collaborating with other team members. Serves as a clinical resource person to staff.
• Demonstrates appropriate and timely use of the EMR, tracking tools, data, and communication platforms.
• Assists with special projects as assigned and completes them within the required timelines.
• Effectively communicates problems, concerns, or issues to the Clinical Manager and/or Providers appropriately and promptly.
• Provides updates to the patient's PCP and communicates with family members as needed.
• Collects, tracks, trends, and reports clinical data, as needed, for Diabetes Program and initiatives.
• Other duties as required.

Physical Job Requirements:

• Physical mobility, which includes movement from place to place on the job, taking distance and speed into account.
• Physical agility, which includes ability to maneuver body while in place.
• Dexterity of hands and fingers.
• Endurance (e.g. continuous typing, prolonged standing/bending, walking).

Education, Certification, Computer and Training:

Required:

• Bachelor's Degree from an accredited Nursing School
• Valid New Jersey RN License Required.
• Minimum of 2 years nursing experience in primary care or endocrinology
• Diabetes Educator Certification - If not certified at time of hire, must obtain certification within 18 to 24 months.
• Valid Driver's License required & proof of valid vehicle insurance (NJ Coverage limits required).
• Excellent written, verbal and listening community abilities. Communicate appropriately and clearly to staff and providers.
• Computer literacy, including, by not limited to, data entry, retrieval, and report generation.
• Proficient Microsoft Office 365 skills required.
• Ability to work remotely and to work well in a virtual environment.
• Meet technical requirements to work remotely.
• Experience with standard office equipment (phone, fax, copy machine, scanner, email/voice mail) required.

Preferred:

• A minimum of 2 years Care/Case Management Experience or comparable clinical experience preferred.
• Certified Case Manager (CCM).

Travel:

• Travel required for offsite meetings and to clinical offices.

Position Type/Expected Hours of Work:
RN/LPN (Full-time 40 hrs.) Monday - Friday.

Ability to work weekends and flexible hours as needed.

About Our Commitment

Total Rewards at VillageMD

Our team members are essential to our mission to reshape healthcare through the power of connection.

VillageMD highly values the critical role that health and wellness play in the lives of our team members and their families.

Participation in VillageMD's benefit platform includes Medical, Dental, Life, Disability, Vision, FSA coverages and a 401k savings plan.

Equal Opportunity Employer

Our Company provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to, and does not discriminate on the basis of, race, color, religion, creed, gender/sex, sexual orientation, gender identity and expression (including transgender status), national origin, ancestry, citizenship status, age, disability, genetic information, marital status, pregnancy, military status, veteran status, or any other characteristic protected by applicable federal, state, and local laws.

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Our Company will never ask for money or an exchange of money, banking or other personal information prior to the in-person interview.

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