Patient Support Care Navigator

Lifespan; Providence (RI); On-site; USD 29,000 - 48,000; Full time

Job summary

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.

Responsibilities

• 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

Tools

EMR

Job description

SUMMARY

Supports the Nurse Care Management department in caring for rising-risk and high-risk patients and plays a key role in obtaining information about patients with medical and social needs.

Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another.

In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include:

• Instill Trust and Value Differences
• Patient and Community Focus and Collaborate

RESPONSIBILITIES

• Screens patient census using provided criteria to determine if the patient should be categorized as high risk
• Manages the high-risk patient census to assess if intervention from the Nurse Care Manager (NCM) or other disease management/population health program is needed
• Assesses patients for basic needs and intervenes when appropriate, referring patients with greater needs to the NCM for intervention
• Works closely with the NCM to help patients reach their goals, maintain safety and improve their health
• Has awareness and understanding of community and BHMGPC resources/teams to offer patients
• Hands off communication to the NCM or other BHMGPC program when necessary
• Works with the NCM to develop and update patient care plans and attends care conferences and huddles as needed
• Performs telephonic and remote patient outreach to patients, documenting all outreach and interventions in the electronic medical record (EMR)
• Facilitates and reinforces patient self‑management under the direction of the NCM and encourages patients to keep up to date with labs, PCP and specialist visits and their care plan
• Evaluates for patient safety
• Ensures documentation is collected from patient specialist visits
• Provides resources and disease management education to patients
• Comfortable with MOLST and durable power of attorney forms to lightly discuss with patients
• Understands durable medical equipment (DME) needs and referrals
• Has in-depth understanding of medical insurances and benefits
• Assists patients with transportation needs
• Performs other job-related duties as assigned

MINIMUM QUALIFICATIONS

Pay Range: $20.96-$34.61

EEO Statement: Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.

Location: Brown Health Medical Group Primary Care - 593 Eddy St - Executive Suite Providence, Rhode Island 02903

Work Type: Monday - Friday 7:30a-4:00p

Work Shift: Day

Daily Hours: 8 hours

Driving Required: No