Dementia Care Navigator

1 week ago


Boston, Massachusetts, United States Tufts Medicine Full time
Job Profile

This role focuses on delivering high-quality patient care by evaluating, developing, and implementing policies and procedures. The Care Navigator will work closely with patients, families, and healthcare teams to ensure seamless transitions across the care continuum.

Job Overview

This position supports and facilitates transitions across the care continuum through telephonic patient outreach, coordination of care, and referrals to providers and agencies. The Care Navigator will act as a liaison between providers and clinical resources to ensure patients are actively involved in decision-making for all aspects of care.

Key Responsibilities
  • Creates and distributes daily patient activity reports to provider offices.
  • Reviews, authorizes, and assigns referral requests submitted for review.
  • Provides hospital admission report review and production of review sheets for level of care review.
  • Tracks, documents, and plans level of care determinations.
  • Identifies authorization/denial/pending, level of care assigned, and number of days to be paid.
  • Reviews and distributes walk-around reports to provider offices.
  • Schedules and/or ad-hoc research and documentation as deemed appropriate by Clinical Operations and Programs Sr. Manager.
  • Communicates to clinic offices, office managers via email and presentations at meetings.
  • Runs daily admission and discharge lists for resource team and skilled nursing facility nurse practitioner and prepares team list for appropriate follow-up for the day.
  • Monitors emergency department utilization at set intervals throughout the day and communicates information to assigned clinical staff for real-time intervention.
  • Conducts telephonic patient outreach for patients discharged from the inpatient setting, emergency department, and skilled nursing facility to ensure transitions of care.
  • Develops trusting, professional, caring relationships with patients and families, engaging respectfully and with utmost attention to service.
  • Collaborates with other members of the Resource Team, enrolls patients, and maintains registries and spreadsheets to support these programs.
  • Schedules appointments for patients and makes referrals as needed for transportation, etc.
  • Maintains collaborative, team relationships with peers and colleagues in order to effectively contribute to the team's achievement of goals, and to help foster a positive work environment.
Requirements
  • High school diploma or GED.
  • Two (2) years of experience in a clinical setting (nursing unit, care management, physician's office).
Preferred Qualifications
  • College Degree.
  • Medical Assistant (MA) certification.
  • Three (3) years of related experience.
Physical Requirements
  • Frequent sitting, occasional standing & walking, and lifting of 5-10 lbs.
  • Requires manual dexterity using fine hand manipulations.
  • Requires ability to see computer screen and reports.
  • Workstation space is limited; narrow aisles.
  • Noise level can be high at times - multiple conversations at one time.
  • High stress factor with department activity.
Skills & Abilities
  • Customer-focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary healthcare team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
  • Ability to work autonomously in established situations and be accountable to the goals of the department.
  • Ability to influence and negotiate with individuals.
  • Ability to function effectively in a fluid, dynamic, and rapidly changing environment.
  • Familiarity with the target community and feels connected to that community.
  • Ability to work well with people of various ages, backgrounds, ethnicities, and life experiences.
  • Ability to prioritize and resolve critical issues efficiently and effectively.
  • Detail-oriented, with strong organizational skills and multi-tasking abilities.
  • Experience with Electronic Medical Records and possess a willingness and ability to learn and utilize new technology and procedures that will continue to develop in their role and throughout the organization.
  • General computer knowledge and ability to use computers required. Very strong working knowledge and proficiency with technology and business software (Microsoft Office, Word, Excel).


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