Care Navigator
2 weeks ago
About Our Company
We're a physician-led, patient-centric network committed to simplifying healthcare and bringing a more connected kind of care.
Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients' homes, and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD, and Starling Physicians.
When you join our team, you become part of a compassionate community of people who work hard every day to make healthcare better for all.
We are innovating value-based care and leveraging integrated applications, population insights, and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care.
Job Description Position Summary:
The Care Navigator directly supports and promotes the care transitions and social support needs of patients across the continuum of care and supports quality improvement initiatives through targeted outreach to patients who are not meeting clinical goals.
This position collaborates with providers, RN Care Managers, Social Workers, and others to facilitate seamless transitions of care, social support interventions, and patient outreach and engagement to close care gaps, with the goal of assuring superior patient experience and quality outcomes.
The Care Navigator networks internally with clients and externally to all care settings to obtain needed clinical information, engage and educate patients, identify risk factors for referrals, and perform an integral role in clinical data collection, tracking, trending, and reporting on all outcomes.
Essential Job Functions:
- Establishes and maintains external relationships with hospitals, rehabilitation facilities, and other post-acute care facilities by: (1) Promoting ongoing collaboration and regular communications with facilities and providers; (2) Conducting & documenting routine/weekly outreach calls to all facilities to gather critical clinical information about admitted patients; and (3) Demonstrating effective relationship-building skills
- Works collaboratively with both internal and external entities to facilitate seamless transitions across the continuum of care by adhering to departmental administrative TOC workflow standards.
- At time of patient discharge, initiates and completes the TOC process on behalf of client's providers and ensures a seamless handoff of information to RN Care Managers and other interdisciplinary team members for further follow-up post-discharge.
- Manages low-risk patients discharged from an inpatient facility by providing outreach to the patient and adhering to an established care pathway and algorithm designed for the outreach process for low-risk patients.
- Collaborates with Social Support team and manages the Information, Referral, and Assistance inquiries received; ensures that outreach to patient/family member/caregiver is completed in a timely and efficient manner.
- Identifies patients not meeting clinical goals or important quality metrics and arranges follow-up by protocol, as appropriate. Uses registry tools to identify and track patients. Conducts follow-up activities with patients who have not kept important appointments or completed needed diagnostic testing.
- Identifies patients and families who would benefit from additional care management/social work support and makes appropriate referrals.
- Reviews and updates medication list and accurately documents known allergies in the Electronic Health Record (EHR). Demonstrates an understanding of prescription control and prescription refill procedures.
- Records patient information accurately to support population health initiatives. Updates data worksheets with outcomes following patient contact and recommendation of needed services and appointments.
- Facilitates and arranges new patient and follow-up services per treatment protocol, as appropriate.
Home Visit Job Functions:
- Actively engages and collaborates with RN Care Managers, Social Worker, clinic staff, and providers, as applicable, to schedule and prepare for identified in-home virtual visits.
- Communicates with patients during in-home virtual visits and completes rooming process that includes facilitates technology to initiate visit, perform standard Epic rooming workflow, obtaining vitals, completing screenings, and collect lab specimens as needed post-office visit based on provider after-visit orders for patient.
- Maintains HIPPA-compliant workflow while in patients' home and while transporting any specimens and documentation to clinic.
- Manages supplies and equipment needed for home visit such as tablet, computer, hot spot, vital signs, and lab collection equipment.
Education, Certification, Computer, and Training Requirements:
- Bachelor's Degree preferred but not required.
- 2-4 years of relevant work experience in the healthcare field is preferred.
- Certified Medical Assistant, Licensed Practice Nurse in the State of Oregon, EMT-B or Paramedic preferred, or other relevant clinical experience considered.
- BLS certification required for in-person patient-facing positions. This is not applicable for positions that work remotely.
- Valid Driver's License for patient-facing positions. This is not applicable for positions that work remotely.
- Experience in primary care, family practice, internal medicine, urgent care, or ER preferred.
- Must be proficient in computer skills.
- Must be proficient in Microsoft Office, Excel, Word, and PowerPoint.
Total Rewards at VillageMD
Our team members are essential to our mission to reshape healthcare through the power of connection.
VillageMD highly values the critical role that health and wellness play in the lives of our team members and their families.
Participation in VillageMD's benefit platform includes Medical, Dental, Life, Disability, Vision, FSA coverages, and a 401k savings plan.
Equal Opportunity Employer
Our Company provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to, and does not discriminate on the basis of, race, color, religion, creed, gender/sex, sexual orientation, gender identity and expression (including transgender status), national origin, ancestry, citizenship status, age, disability, genetic information, marital status, pregnancy, military status, veteran status, or any other characteristic protected by applicable federal, state, and local laws.
Safety Disclaimer
Our Company cares about the safety of our employees and applicants. Our Company does not use chat rooms for job searches or communications. Our Company will never request personal information via informal chat platforms or unsecure email.
Our Company will never ask for money or an exchange of money, banking, or other personal information prior to the in-person interview.
Be aware of potential scams while job seeking. Interviews are conducted at select Our Company locations during regular business hours only. For information on job scams, visit, or file a complaint.
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