Clinic Chronic Care Navigator

Description PURPOSE STATEMENT: Responsible for assisting in coordinating team-based care, to provide health services to individuals, through effective partnership with patients, their caregivers/families, community resources and members of the Care Team. ESSENTIAL FUNCTIONS · Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.

· Work with RN’s and payers to plan and monitor patient care. · Assess patient’s unmet health and social needs. · Facilitate patient access to appropriate medical and specialty providers. · Educate patient and family/caregiver(s) about relevant community resources. · Facilitate and attend meetings between care team, payers, and community resources, as needed · Assist with the identification of “high-risk” patients (the chronically ill and those with special health care needs), and add these to the patient registry (or flag in EHR) · Follow up and monitor patients via payer work lists to assist in scheduling and following patient chronic care diagnosis.

· Attend all Care Coordinator training courses/webinars and meetings · Display knowledge of preventative health requirements · Maintain regular and predictable attendance · Perform other essential duties as assigned Requirements EDUCATION/EXPERIENCE/SKILL REQUIREMENTS · Current Certified Medical Assistant certification or licensed practical nurse Two years’ experience as a CCMA or LPN required · BLS · Previous experience in caring for chronic disease patients preferred · Two years’ experience in clinical or community health setting preferred · Previous Care Coordination, Case Management or Home Health experience preferred · Must be self-motivated and have the ability to work within the established policies, procedures and practices prescribed by the hospital/clinic.