Patient Care Navigator: High-Risk Support & Outreach

Lifespan; Providence (RI); Sur place; USD 29 000 - 48 000; Plein temps

Résumé du poste

Brown University Health's Primary Care team in Providence, RI seeks a Nurse Care Management support role to assist rising-risk and high-risk patients. You will help obtain information about patients with medical and social needs and support care planning in collaboration with the NCM.

You will perform telephonic and remote outreach, document interventions in the EMR, and connect patients with needed resources while reinforcing self-management and safety throughout the care plan.

Responsabilités

• Screens patient census to determine if the patient should be categorized as high risk
• Manages the high-risk patient census to assess intervention needs
• Assesses patients for basic needs and refers to the NCM for intervention
• Collaborates with the NCM to help patients reach goals and stay safe
• Liaises with community resources to support patient needs
• Hands off communication to the NCM or program when necessary
• Develops and updates patient care plans and attends care conferences
• Performs telephonic and remote outreach and documents in the EMR
• Encourages patient self-management and adherence to labs and visits
• Evaluates patient safety and suitability for interventions
• Ensures documentation from specialist visits is collected
• Provides disease management education and resources to patients
• Comfortable discussing MOLST and DPOA forms with patients
• Assesses DME needs and referrals as appropriate
• Understands medical insurances and benefits
• Assists patients with transportation needs
• Performs other duties as assigned

Outils

EMR

Description du poste

Brown University Health's Primary Care team in Providence, RI seeks a Nurse Care Management support role to assist rising-risk and high-risk patients. You will help obtain information about patients with medical and social needs and support care planning in collaboration with the NCM.

You will perform telephonic and remote outreach, document interventions in the EMR, and connect patients with needed resources while reinforcing self-management and safety throughout the care plan.