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Job Summary

Under the direction of the Care Management Leadership team, the Registered Nurse High Risk Patient Care Navigator will provide high level clinical support for identified High Risk patients with complex medical conditions and transition of care by identifying gaps through close monitoring via telephonic outreaches empowering patients with education and management of acute or chronic conditions. The Registered Nurse High Risk Patient Care Navigator will serve as a resource, mentor and support for the Care Management Coordinators and Regional Managers. The Registered Nurse High Risk Patient Care Navigator serves as an intermediary between the Interdisciplinary Care Teams and the patient and/or family, fostering a team-based approach ensuring continuity of care.

Essential Duties & Responsibilities

• Patient Assessment:
• Evaluate the needs of patients to understand their medical, social determinants of health and psychological needs through interviews, medical records review, and data analysis
• Care Planning:
• Develop individualized Care Plans that outline the goals and services necessary for the patient’s wellbeing to optimize health outcomes
• Coordination of Services:
• Work with the Interdisciplinary Team and other stakeholders to ensure timely and effective care
• Monitor and Evaluate:
• Track patient’s progress and adjust care plans as necessary to meet patient’s changing needs and ensure adherence to treatment regimens
• Patient Advocacy and Education:
• Educate patient and/or caregiver about managing their health conditions, treatment options, lifestyle modifications and self-management strategies
• Empower patients to actively participate in their care and make informed decisions.
• Ensure patients have access to necessary resources, including community support services
• Documentation:
• Maintain accurate records of care plans, telephonic encounters and other relevant patient information
• Compliance:
• Ensure care is provided in compliance with Value Based Care guidelines
• Review medical records to ensure appropriate utilization of healthcare services
• Clinical Guidance:
• Educate, train, mentor and serve as a resource to the Care Management Care Coordinators from a clinical perspective.
  
  

Supervisory Responsibilities

• No supervisory responsibilities.
  
  

Critical Results

• Decrease avoidable APT/EPT/Readmissions for High-Risk Patient Population by 10%
  
  

Education & Experience

• Registered Nurse (RN) License: Current and active RN license required
• Experience: Minimum of 3 years of clinical Nursing experience
• Experience in Disease Management required
• Experience in Care Management or Case Management preferred
• Experience with Value Based Programs preferred
• Strong organizational, leadership and communication skills
• Must be fully bilingual English/Spanish
  
  

Required/Preferred

Education Requirements

Education Level

Discipline

Required

Technical Degree

Must hold a current and active RN license.

Knowledge, Skills & Proficiencies

• Problem-Solving: Strong critical thinking and problem-solving skills, with proactive approach to identifying and addressing operational and quality-related challenges
• Data-Driven Mindset: Strong analytical skills with the ability to interpret complex data sets and utilize data to inform decision-making.
• Communication Skills: Excellent verbal and written communication skills, with the ability to effectively engage and influence stakeholders at all levels of the organization.
• Tech Savvy: Proficiency with electronic health record (EHR) systems, healthcare analytics tools, and Microsoft Office Suite (Word, Excel, PowerPoint).
  
  

Physical Requirements

This position works under usual office conditions. The employee is required to work at a personal computer as well as be on the phone for extended periods of time. Must be able to stand, sit, walk, and occasionally climb. The incumbent must be able to work flexible. Physical demands include the ability to lift to 50 lbs. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Work Conditions

Must be able to perform essential functions such as typing, standing, sitting, stooping, and occasionally climbing

Travel Requirements

Amount of Expected Travel

Details

No

Tools & Equipment Used

Computer and peripherals, standard and customized software applications and tools, and usual office equipment.

Disclaimer

The duties and responsibilities described above are designed to indicate the general nature and level of work performed by associates within this classification. It is not designed to contain, or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of associates assigned to this job. This is not an all-inclusive job description; therefore, management has the right to assign or reassign schedules, duties, and responsibilities to this job at any time. Cano Health is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.

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