Care Navigator - Population Health

Lehigh Valley Health Network; Pennsylvania; Remote; USD 80,000 - 100,000; Full time

Job summary

Lehigh Valley Health Network, Inc. seeks an experienced RN for care coordination and case management. You will implement individualized care plans, educate patients and families, and collaborate with a multidisciplinary team to ensure seamless transitions across the care continuum.

You will review medications, maintain accurate EHR documentation, and use data registries to drive quality improvements. Strong communication and cultural competence are required.

Qualifications

• Bachelor’s Degree in Nursing required; experience in lieu of degree may be considered.
• Active PA RN license required; CACRN or CCCTM certifications preferred.
• 5+ years RN experience with 2+ years in case management or care coordination.
• 2+ years EMR experience and comfort with data to drive care decisions.
• Ability to coordinate care across multidisciplinary teams and settings.

Responsibilities

• Identify patients not meeting clinical goals and arrange follow-up per protocol.
• Review and update medication lists; document known allergies in EHR.
• Utilize registries and data with evidence to support care decisions and improvements.
• Identify variances in standards of care that could impact safety or cost.
• Establish and maintain relationships with hospitals and post-acute facilities.
• Provide care navigation for LVHN Specialty Institutes and related programs.
• Collaborate with patient/family to set mutual goals based on needs.
• Address barriers (transportation, financial, psychosocial) and coordinate solutions.

Skills

RN (Registered Nurse)

Case management

Care coordination

EMR literacy

Interdisciplinary collaboration

Education

Bachelor’s Degree in Nursing

PA RN License

CACRN

CCCTM

Tools

EMR/EHR

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.

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