VBC Care Navigator

Job Description

SUMMARY

The VBC Care Navigator's primary job responsibility is to effectively guide and coordinate care for patients with complex healthcare needs. The Care Navigator will act as the first point of patient contact for incoming or outbound Kidneylink calls. Schedule calls with our interdisciplinary clinical team and gather and verify demographic information, utilize tools and critical thinking, and route calls as appropriate following standard operating procedures.

Essential Duties and Responsibilities include the following. Other duties and tasks may be assigned.

Engagement:

Conduct welcome calls to introduce patients to the program and its benefits. Initiate outreach efforts to engage patients and build rapport. Schedule appointments and facilitate initial patient engagement. Patient Activation Measure (PAM) Screening: Administer PAM assessments to gauge patients' readiness for active self-care. Utilize assessment results to tailor care plans accordingly. PHQ-9 Screening and Escalation: Conduct PHQ-9 screenings to assess patients for depression. Initiate the escalation pathway for patients with PHQ-9 scores above 9. Advanced Directives Screening: Assess patients' awareness and understanding of advanced directives. Offer education on advanced directives and assist with documentation.

IDT Scheduling:

Collaborate with the Interdisciplinary Team (IDT) to schedule patient appointments. Ensure timely coordination of care among team members. Demographic Information Verification: Verify and update patient demographic information to maintain accurate records. Panel Management and Appointment

Scheduling:

Manage a panel of patients, ensuring their appointments with Kidneylink (KL) are scheduled appropriately. Coordinate with patients to ensure adherence to their care plans. Medication Entry and Pharmacist Referrals: Enter medication information into the system for proper tracking. Refer patients to pharmacists for medication-related queries and guidance. Social Determinants of Health (SDOH) Assessment: Screen patients for social determinants of health, addressing potential barriers to care.

Care Coordination Tasks:

Receive care coordination tasks assigned by Registered Nurses (RNs). Implement care coordination plans and strategies as directed. Hospitalization Screening and TOC Workflow: Screen for hospitalizations, emergency room visits, and inpatient stays. Initiate Transitional Office Care (TOC) workflow for seamless post-hospital care. External Continuity of Care: Monitor patients' external continuity of care, including PCP appointments and dialysis clinic visits. Ensure patients are linked to necessary follow-up care.

EMR Documentation:

Document patient interactions and relevant information in the physician's Electronic Medical Record (EMR). Utilize tools such as CKCC flags to indicate critical patient information. TOC Follow-Up Appointments: Facilitate follow-up appointments after hospital visits through shared tools. Notify healthcare practices of required patient follow-up. Issue Identification and Escalation: Identify emerging issues during patient interactions and escalate them to Registered Nurses for appropriate action.

Optimal Start (OS) Coordination:

Coordinate optimal starts such as access placement, ensuring seamless patient care.

Other:

Participates in team concepts and promote a team effort; performs duties in accordance with company policies and procedures. Regular and reliable attendance is required for the job.

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