Senior Care Coordinator

2 days ago


Stone Mountain, Georgia, United States CenterWell Full time
Job Summary

CenterWell Senior Primary Care is seeking a highly skilled Care Navigator to join our team. As a Care Navigator, you will play a critical role in proactively engaging patients identified as high-risk and implementing targeted interventions to address social needs and increase access to care.

Key Responsibilities
  • Conduct Transitions of Care Management for a subset of the patient population, including ER and hospital 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 supports
  • Lead Interdisciplinary Team Meetings when indicated
  • Assess patient's family system, and conduct family meetings with patient and family when needed
  • Participate in creation and facilitation of team training content
  • Conduct group psychoeducation and support groups within the Center
  • Perform all other duties and responsibilities as required
  • Participate in and lead 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
Requirements
  • Registered Nurse (RN license)
  • Minimum of 4 years of experience working in human services and navigating community-based resources
Preferred Qualifications
  • Familiarity with state Medicaid guidelines and application processes preferred
  • Experience working with patients with behavioral health conditions and substance use disorders preferred
  • Prior experience conducting home visits and knowledge of field safety practices preferred
Working Conditions

This role has a mobile presence, involving travel to patients' homes, treatment facilities and community-based settings, and assigned clinics to facilitate connections.

Benefits
  • Health benefits effective day 1
  • Paid time off, holidays, volunteer time and jury duty pay
  • Recognition pay
  • 401(k) retirement savings plan with employer match
  • Tuition assistance
  • Scholarships for eligible dependents


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