Care Navigator - Population Health

1004 Lehigh Valley Hospital; Pennsylvania; Hybrid; USD 85,000 - 115,000; Full time

Job summary

Lehigh Valley Health Network is seeking a Nurse Care Coordination professional to implement care plans tailored to patients' medical, mental, and social needs. You will work within a multidisciplinary team to ensure smooth transitions before hospitalization and after discharge, guiding patients and families through the continuum of care.

The role emphasizes identifying barriers to access, coordinating with hospitals and post-acute facilities, and providing navigation and education.

Qualifications

• RN licensed in Pennsylvania with a Bachelor's degree or higher.
• 5+ years as an RN with 2+ years in case management or hospital/physician settings.
• 2+ years of electronic medical record (EMR) experience.
• Ability to coordinate care for diverse populations and settings.
• Strong knowledge of public health factors influencing access and delivery.

Responsibilities

• Identify patients not meeting clinical goals and arrange follow-up per protocol.
• Review medication lists and document allergies in the EHR.
• Utilize registry data and evidence to support point-of-care decisions.
• Support quality improvements and participate in pilots and research.
• Develop external relationships with hospitals and post-acute facilities.
• Provide care navigation for LVHN Specialty Institutes and programs.
• Collaborate with patients and families to set mutual goals.
• Identify system barriers and coordinate services to improve access.

Skills

RN experience

EMR experience

Case management

Cultural competence

Education

Bachelor of Science in Nursing (BSN)

Master’s Degree in Nursing (Preferred)

CACRN

CCCTM

MSNCB

Tools

EMR systems

Job description

Imagine a career at one of the nation's most advanced health networks. Be part of an exceptional health care experience. Join the inspired, passionate team at Lehigh Valley Health Network, a nationally recognized, forward-thinking organization offering plenty of opportunity to do great work. LVHN has been ranked among the "Best Hospitals" by U.S. News & World Report for 23 consecutive years. We're a Magnet(tm) Hospital, having been honored five times with the American Nurses Credentialing Center's prestigious distinction for nursing excellence and quality patient outcomes in our Lehigh Valley region.

Finally, Lehigh Valley Hospital - Cedar Crest, Lehigh Valley Hospital - Muhlenberg, Lehigh Valley Hospital- Hazleton, and Lehigh Valley Hospital - Pocono each received an 'A' grade on the Hospital Safety Grade from The Leapfrog Group in 2020, the highest grade in patient safety. These recognitions highlight LVHN's commitment to teamwork, compassion, and technology with an unrelenting focus on delivering the best health care possible every day. Whether you're considering your next career move or your first, you should consider Lehigh Valley Health Network.

Summary

Implements care plans that are specific to each patient's physical, mental, and social needs based on medical and pre-surgical clinical assessments. Ensures smooth transitions and evidence-based disease management for select populations prior to hospitalization and/or a segment of time post-discharge. Works collaboratively as part of a multi-disciplinary team to provide patient and family education and navigation across the continuum of care.

Job Duties

• Identifies patients not meeting clinical goals or important quality metrics and arranges follow-up per protocol, as appropriate.
• Reviews and updates medication list and accurately documents known allergies in the electronic health record (EHR).
• Utilizes registry and other data along with published evidence to assist with the point of care decision making.
• Supports quality improvements, pilot participation, and other research activities.
• Identifies actual or potential variances in standards of care and system problems that could lead to errors, delays in care, complications, or increased cost.
• Establishes and maintains external relationships with hospitals, rehabilitation facilities, and other post-acute care facilities.
• Provides care navigation services to specialty populations, inclusive of LVHN Specialty Institutes and BPCI-A
• Collaborates with patient/family in establishing mutual goals based on the patient's needs and problems.
• Identifies issues related to the healthcare system, transportation, financial, and/or psychological barriers and works collaboratively to problem solve, coordinate services, and advocate for patients/families.

Minimum Qualifications

• Bachelor’s Degree in Nursing. Experience in lieu of Bachelor's degree may be considered. 5 years Experience working as a registered nurse (RN) and 2 years Previous experience in case management, disease management, home health care, hospital, or physician office setting and 2 years Prior electronic medical record (EMR) experience Ability to set priorities to coordinate care plan efficiently. Utilizes effective strategies for interacting with persons from diverse backgrounds. Ability to recognize the role of cultural, social, economic, and behavioral factors in accessibility, availability, acceptability, and delivery of public health services. Knowledge of computer applications and analytical tools. RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire and CACRN - Certified Ambulatory Care RN - State of Pennsylvania Within 3 Years or CCCTM - Cert Care Coord-Transition Mgt MSNCB - State of Pennsylvania Within 3 Years

Preferred Qualifications

• Master’s Degree Nursing 2 years Condition- or population-specific experience (Orthopedics, Cardiac, Pulmonary, GI, Pediatrics)

Physical Demands

• Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Job Description Disclaimer

This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Lehigh Valley Health Network is an equal opportunity employer. In accordance with, and where applicable, in addition to federal, state and local employment regulations, Lehigh Valley Health Network will provide employment opportunities to all persons without regard to race, color, religion, sex, age, national origin, sexual orientation, gender identity, disability or other such protected classes as may be defined by law. All personnel actions and programs will adhere to this policy. Personnel actions and programs include, but are not limited to recruitment, selection, hiring, transfers, promotions, terminations, compensation, benefits, educational programs and/or social activities.

Lehigh Valley Health Network does not accept unsolicited agency resumes. Agencies should not forward resumes to our job aliases, our employees or any other organization location. Lehigh Valley Health Network is not responsible for any agency fees related to unsolicited resumes.

Work Shift: Day Shift Address: 1200 S Cedar Crest Blvd Primary Location: REMOTE IN PENNSYLVANIA Position Type: Remote Union: Not Applicable Work Schedule: Monday-Friday; 8:00a-4:30p with weekend rotation possible Department: 1004-13010 COH-Payor Based Care Coordination

Lehigh Valley Health Network (LVHN) is the region's largest employer and health care provider of choice. Our nearly 20,000 health care professionals take pride in what they do and are driven by our mission to heal, comfort and care for the people of our community.

LVHN is honored to be certified as a Great Place to Work®. LVHN's culture of trust - and the positive things colleagues said about working at LVHN when surveyed by Great Place to Work and Fortune - align perfectly with what makes a great workplace. This designation tells you that LVHN is a great place to work from hire to retire. If you are someone who aligns with LVHN's core values - Compassion, Integrity, Collaboration and Excellence - you will have a rewarding and successful career here.