Patient Support Care Navigator

CMPI Coastal Medical Physicians, Inc., d/b/a Brown Health Medical Group Primary Care; United States; On-site; USD 29,000 - 48,000; Full time

Job summary

Brown University Health is seeking a Nurse Care Manager to support the Nurse Care Management department in Providence, RI. The role focuses on rising-risk and high-risk patients, coordinating care, and ensuring adherence to care plans under the NCM guidance.

Interventions include telephonic outreach, care plan development, and documenting all activities in the EMR, while partnering with community resources to meet patient needs and promote safety and health outcomes.

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

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 As Rhode Island's largest health system and private employer, Brown University Health is the state's premier provider of health services and includes the only Level I Trauma Center for southeastern New England. Today, more than 20,000 people work at Brown University Health and bring their unique skills, experiences, and compassion to their jobs every day. Formed in 1994, Brown University Health is a not-for-profit health system based in Providence, RI comprising three teaching hospitals of The Warren Alpert Medical School of Brown University: Rhode Island Hospital and its Hasbro Children's; The Miriam Hospital; and Bradley Hospital, the nation’s first psychiatric hospital for children; Newport Hospital, Saint Anne's Hospital and Morton Hospital, community hospitals offering a broad range of health services; Gateway Healthcare, the state’s largest provider of community behavioral health care; and Brown Health Medical Group, the largest multi-specialty practice in Rhode Island. Brown University Health is an equal opportunity employer that values diversity of cultural background, race, gender, age, religion, identity, ability, and perspectives - we are actively committed to a diverse workforce that represents the patients and community that we serve. We are invested in creating a respectful, inclusive, and equitable environment that supports the holistic well-being of our employees and their families. Join us and help build a healthier future for our patients - and for yourself. Company Location Belonging and Engagement Nursing Our Mission