LPN - Care Navigator (Fortify)

1 month ago


Norfolk, United States Children's Hospital of the King's Daughters Full time

Full-Time

3 Commercial Place

Clinical

Days

0.0000 Through 0.0000

GENERAL SUMMARY

The Fortify Care Navigator LPN utilizes their skills and knowledge base to provide care coordination for Fortify's emerging risk patients as a member of the Fortify Care Management department. This department is comprised of a diverse group that includes Licensed Care Managers and Care Coordinators who provide care management services to pediatric patients. The Fortify Care Navigator will initiate and complete quarterly telephonic outreach. Outreach encounters may include completing a health risk assessment, social needs assessment, creation of an individualized plan of care, completion of care gaps, and connecting the patient to resources for any social needs. This role reports to the Manager of Care Management (Fortify).

ESSENTIAL DUTIES AND RESPONSIBILITIES

* Provides care that is inclusive and respectful of socioeconomic status, race, ethnicity, age, mental or physical disability, religion, gender, sexual orientation, or national origin.
* Builds open, trusting, respectful relationships with diverse patients and families both remotely and in person.
* Engages critical thinking skills to support the Fortify Care Management team.
* Provides excellent customer service skills.
* Communicates effectively with diverse audiences both orally and in writing.
* Works with interdisciplinary teams to improve patient, family, and community outcomes.
* Electronically documents care according to industry and institutional standards, including HIPAA-compliant documentation.
* The job includes the following essential functions:
* Maintains a record of patients who will require quarterly outreach.
* Registers new patients into the electronic documentation system.
* Assists with facilitating follow-up care after hospital or emergency room visits.
* Identifies community resources to benefit patients and families.
* Completes quarterly health risk assessments for the assigned caseload.
* Completes quarterly social needs screenings and associated referrals; follow-up to ensure referrals are closed loop and completed.
* Utilizes social needs database to initiate and monitor referrals
* Completes an Individualized Plan of Care and ensuring appropriate interventions have been completed to meet goals.
* Collaborates with other members of the multidisciplinary team.
* Communicates ongoing care needs, referrals and outcomes to interdisciplinary team members to include Fortify Cares team members as well as collaborative medical and community partners.
* Works in collaboration with other care team members and care providers, including behavioral health, disease care management, home care, social work and community-based organizations, to help client achieve optimal health outcomes.

LICENSES AND/OR CERTIFICATIONS

* Current and unrestricted licensure as a Licensed Practical Nurse (LPN) in the state of Virginia.
* CCM Preferred.

MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS

* Completion of an accredited Licensed Practical Nurse program.
* 3+ years professional healthcare experience required.
* Ability to critically think and apply that knowledge to varying patient needs.
* Previous experience working remotely.
* Experience working with children, families, and community partners.
* Proficiency with computers and documentation in the electronic health record.

WORKING CONDITIONS

This is a remote position and requires a home office.

PHYSICAL REQUIREMENTS

Click here to view physical requirements.



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