Senior Care Coordinator
4 weeks ago
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
- Registered Nurse (RN license)
- Minimum of 4 years of experience working in human services and navigating community-based resources
- 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
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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Care Navigator
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Stone Mountain, Georgia, United States CenterWell Senior Primary Care Full timeAbout the RoleCenterWell Senior Primary Care is seeking a skilled Care Navigator to join our interdisciplinary care team. As a key member of our team, you will play a vital role in providing proactive, preventive care to our senior patients. Your primary responsibility will be to engage high-risk patients and implement targeted interventions to address...
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Stone Mountain, United States CenterWell Home Health Full timeBecome a part of our caring community and help us put health first Working within an interdisciplinary care team, the Care Navigator is responsible for proactively engaging patients identified as high-risk and implementing targeted interventions to address social needs and increase access to care. The Care Navigator will provide guidance and oversight of...
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