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Clinical Care Navigator

2 months ago


Orlando, Florida, United States Orlando Health Full time

Position Overview:

Orlando Health Medical Group is a leading healthcare provider dedicated to serving patients throughout the southeastern United States. With a robust network of over 200 practices and 1,200 healthcare professionals, we excel in more than 55 specialties, including cardiology, vascular medicine, orthopedics, oncology, digestive health, neurology, neurosurgery, bariatric surgery, general surgery, bone marrow transplant, and critical care medicine, along with over 30 pediatric subspecialties, women's health, primary care, and the largest hospitalist program in Florida.

As part of the Orlando Health system, which encompasses 24 award-winning hospitals and ERs, 9 specialty institutes, 14 urgent care centers, and more than 60 outpatient facilities, we uphold a century-long legacy of providing exceptional care for over 142,000 inpatient and 3.9 million outpatient visits annually.

Role Summary:
As a Clinical Care Navigator, you will work closely with the designated clinical team to identify patients who would benefit from care coordination services. This includes evaluating patients' risk factors and determining the need for care coordination, clinical utilization management, and preventive care services.

Key Responsibilities:
1. Ensure seamless continuity of care across various settings (inpatient, emergency, and outpatient) to facilitate integrated delivery of services, including comprehensive discharge planning and follow-up care.
2. Foster effective collaboration with Patient and Family Counselors/Social Workers and Utilization Review Nurses to engage patients and families in advocacy and problem-solving, enhancing their functional capabilities while ensuring timely discharge planning.
3. Monitor daily progress towards discharge plans, adjusting as necessary based on changes in patient condition and family needs, prioritizing those at highest risk for complications or readmissions.
4. Educate patients and families with chronic illnesses on evidence-based care standards and self-management strategies.
5. Identify support needs for patients and families, developing actionable plans and providing guidance in overcoming challenges.
6. Facilitate patient access to prescriptions, durable medical equipment (DME), and other identified services.
7. Collaborate with the clinical team to evaluate treatment options, track patient progress towards care plan goals, and revise plans as needed.
8. Advocate for patients to optimize their healthcare needs, including safety, physical, legal, and financial well-being.
9. Refer patients to educational resources regarding healthcare delivery, reimbursement systems, and community services.
10. Utilize available IT resources to enhance registry reporting and maintain specified patient populations, improving disease outcomes through evidence-based guidelines.

Qualifications:
Education: Bachelor of Science in Nursing.
Licensure: Current RN license in the State of Florida; BLS/healthcare provider certification.
Experience: Minimum of three years of direct clinical experience in the relevant population.