Comprehensive Care Navigator
2 days ago
About LifeBridge Health
We are one of the largest healthcare providers in Maryland, serving over 1 million patients annually.
Our team of 13,000 dedicated professionals strives to deliver exceptional care with compassion and excellence.
Job Summary:
The Community Care Coordinator plays a vital role in promoting the health and well-being of assigned patients through face-to-face and phone outreach.
This position is part of our interdisciplinary team, working under the supervision of a Community Care Manager or Supervisor to ensure timely access to necessary services for our patients.
Main Responsibilities:
- Contacting patients, caregivers, and families to ensure preventive services are received by assigned patients
- Decreasing identified care gaps by working with primary care offices to obtain timely appointments for assigned patients
- Applying principles of population health management to identify patients with uncontrolled chronic conditions and/or rising risk indicators and referring them to the Community Care Manager accordingly
- Providing care coordination services for patients requiring chronic care management
- Evaluating and referring patients to the Community Care Manager as appropriate when acuity changes
- Following treatment plans of patients as written by providers and/or Community Care Managers
- Assessing patient needs in their home environment and assisting the IDT to evaluate the patient's needs to facilitate self-management skills
- Leading IDT discussions in home management of assigned patients, including facilitating home care referrals where necessary
- Facilitating discussion with patients and family members on advance directives where necessary
- Linking patients with community resources such as prescription assistance
- Assisting patients in navigating social and health services, including enrollment in social security, Medicaid, Medicare, and other appropriate insurance plans
- Assessing and assisting patient safety needs in their home, including fall risk and ordering equipment where necessary to promote independence
- Assisting with medication self-management, including setting up medication boxes if needed
- Referring patients or families to community resources for housing or treatment to assist in recovery from chronic illness and following up to ensure service efficacy
- Educating and aiding family members to understand, deal with, and support patients with chronic illnesses and end-of-life practices
- Interviewing clients about activities of daily living to determine needs and linking with community resources where necessary
- Reviewing and updating provider and Community Care Manager records of patients' living conditions and ability to adhere to their plan of care and coordinate treatment goals
- Assessing, monitoring, and evaluating patient progress in the home with respect to treatment goals
- Documenting findings in healthcare records according to system-approved protocols
- Collecting data, maintaining records, developing, and utilizing assessment and measuring tools relative to patient care and wellness practices
- Obtaining and coordinating access with primary care providers and other specialty providers, ensuring necessary records and documentation of referrals are completed and reconciled
- Educating patients on available resources for primary care and acute care, as well as alternative community programs and services that promote sound health, lifestyle, and well-being
- Scheduling timely and appropriate office and follow-up visits at/with other healthcare providers, such as dentists, public health, social services, or any other outreach workers necessary to provide comprehensive and quality care for patients
Requirements:
- Licensed Practice Nurse or Certified Medical Assistant or trained Patient Care Assistant with 2-3 years acute care and/or ambulatory practice experience
- Preferably with experience working with care managers from an acute care setting or health insurance and/or other payer entities
- Good verbal and communication skills and organizational skills are essential
- Competency in electronic medical records is desirable
- Bilingual preference (market-specific)
Salary:$17.00-$26.00/hour based on experience
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