RN Primary Care Navigator | Polson Primary Care Clinic

One Sky Health Kalispell Medical Center; Polson (MT); On-site; USD 70,000 - 100,000; Full time

Benefits offered by this job

Health benefits

401(k) matching

Tuition Reimbursement Program

Life insurance

Job summary

Logan Health in Polson, MT is seeking a registered nurse to join the Care Navigation team. The role focuses on enrolling patients in chronic care management, educating on program benefits and coordinating care across multiple settings to improve outcomes for patients with chronic conditions.

The position emphasizes strong communication, organization, and teamwork. A Montana RN license is required; Bachelor’s degree is preferred, with accessibility to resources for patients and families.

Qualifications

• Current Montana RN license or multi-state compact with authorization to practice in Montana.
• Bachelor’s Degree in Nursing preferred.
• RQI Provider (BLS) within 7 days of hire/transfer.
• Computer skills: Word, Outlook, Excel, PowerPoint, Access; ability to learn other software.
• Knowledge of electronic health records preferred.
• Must work with autonomy, strong communication and interpersonal skills.
• Understanding of the health care continuum and problem-solving abilities.
• Experience collaborating with multidisciplinary care teams.
• Knowledge of value-based payment models and Medical Home care model preferred.

Responsibilities

• Enroll patients in the CCM Program and educate them on program benefits.
• Outreach to patients that may need care navigation services.
• Provide patient education on chronic disease management, medication adherence, and treatment plans.
• Coordinate care across primary care, specialty services, inpatient and outpatient settings.
• Facilitate scheduling of appointments, referrals, diagnostic testing, and procedures.
• Assist patients in accessing resources for housing, care assistance, and placement services.
• Engage with providers to facilitate communication and optimize outcomes.
• Track patient progress and follow up to ensure effective care management.

Skills

Communication skills

Organization

Attention to detail

Team collaboration

Patient-centered care

Chronic condition management (RN)

Education

Montana RN license

Bachelor’s Degree in Nursing (preferred)

Tools

Word

Outlook

Excel

PowerPoint

Access

EHR systems

Job description

Where this position is located

This role will be located at our Polson, MT, Primary Care Clinic at 106 Ridgewater Dr Suite A, Polson, MT.

Key Responsibilities

• Enroll patients in the CCM Program and educate them on program benefits.
• Outreach to patients that may need care navigation services.
• Provide patient education on chronic disease management, medication adherence, and treatment plans.
• Coordinate care across multiple settings such as primary care, specialty services, inpatient and outpatient settings.
• Facilitate timely scheduling of appointments, referrals, diagnostic testing, and procedures.
• Assist patients in accessing resources for housing, care assistance, and placement services.
• Engage with primary care and specialty providers to facilitate communication and optimize patient outcomes.
• Track patient progress and provide follow up as needed to ensure effective care management.

What We’re Looking For

• Strong phone and in-person communication skills
• Self-starter, organized, and detail-oriented with excellent follow-up skills.
• Team player who collaborates well across disciplines and works independently when needed.
• Caring and compassionate demeanor with a positive attitude and commitment to patient-centered care.
• Experienced RN with history of managing chronic conditions is highly preferred.

Why Join Us?

No Weekends! No Holidays! Supportive & Collaborative Environment: Work with a dedicated team that values trust, teamwork, and excellence. Opportunities for Growth: Expand your skills in care coordination, chronic disease management, and patient advocacy.

Competitive Compensation & Benefits: Affordable health benefits, generous matching 401(k), Fitness Center membership discount, Tuition Reimbursement Program, and employer paid life insurance!

Qualifications

• Current Montana RN license or a multi state compact license with authorization to practice nursing within the state of Montana; required.
• Bachelor’s Degree in Nursing preferred.
• RQI Provider (BLS) within 7 days of hire/transfer or before independent patient care, whichever comes first.
• Possess and maintain computer skills to include working knowledge of Word, Outlook, Excel, PowerPoint, Access and ability to learn other software as needed.
• Knowledge of electronic health records preferred.
• Must function with a high degree of autonomy, communication and interpersonal skill.
• Must understand the health care continuum and have the ability to solve complex problems.
• Demonstrated ability to work collaboratively with multidisciplinary medical home care teams.
• Knowledge of professional practice standards, regulatory requirements, and systems operations required.
• Nursing experience in a variety of care settings (Outpatient Clinic, SNF, Home Health, and Acute Care) preferred.
• Knowledge of Value-based payment models and the Medical Home care model preferred.
• Ability to evaluate clinical outcomes across a variety of primary care settings and familiarity with diabetes and lipid management, including dietary assessment preferred.
• Excellent organizational skills, detail-oriented, a self-starter, possess critical thinking skills and be able to set priorities and function as part of a team as well as independently.
• Commitment to working in a team environment and maintaining confidentiality as needed.
• Excellent verbal and written communication skills including the ability to communicate effectively with various audiences.
• Excellent interpersonal skills with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.

Other Job Specific Duties

• Assesses patient needs upon initial encounter and periodically throughout navigation.
• Matches unmet needs with appropriate services, referrals and support services, such as dietitians, providers, social work, pharmacy, and financial services.
• Acts as a liaison between the patients, families, caregivers and the providers to optimize patient outcomes.
• Identifies high risk patients who would benefit from chronic care management and works collaboratively with the primary care provider, patient, and family to develop an individualized patient-centered plan of care.
• Participates in coordination of the plan of care with the multidisciplinary team, promoting timely follow-up on treatment.
• Facilitates timely scheduling of appointments, referrals, diagnostic testing, and procedures to expedite the plan of care and to promote continuity and quality care.
• Utilizes appropriate assessment tools (e.g., PHQ2/9, mini cog, pain scale, etc.) to promote a consistent, holistic plan of care.
• Provides psychosocial support to and facilitates appropriate referrals for patients, families, and caregivers, especially during periods of high emotional stress and anxiety.
• Provides and reinforces education to patients, families, and caregivers about chronic disease process, discharge teaching/instructions, new diagnosis, and medications.
• Builds therapeutic and trusting relationships with patients, families, and caregivers through effective communication and listening skills.
• Utilizes motivational interviewing techniques to assist patients in meeting goals and managing chronic disease.
• Facilitates communication among members of the multidisciplinary primary care team to prevent fragmented or delayed care that could adversely affect patient outcomes.
• Supports a smooth transition of care for patients from one level of care to another.
• Provides acute care, skilled nursing facility, and emergency department (ED) follow up.
• Participates in the tracking of metrics and patient outcomes, in collaboration with administration, to document and evaluate outcomes of the navigation program.
• Focuses on prevention measures consistent with established guidelines and care process models and works toward continuously improving quality metrics and closing care gaps.
• Collaborates with the care navigation team to develop and improve workflows and protocols for primary care that ensure hospital, ED, and community resource follow-up.
• Exhibits effective communication with peers, members of the multidisciplinary healthcare team, and community organizations and resources.
• Works collaboratively with fellow members of the Care Navigation team, providers, and integrated multi-disciplinary team members.

Shift

Day Shift - 8 Hours (United States of America) Schedule: Full-time, 40 hours per week, 8-hour day shifts. Monday - Friday, no Holidays, no weekends. Logan Health operates 24 hours per day, seven days per week. Schedules are set to accommodate the requirements of the position and the needs of the organization and may be adjusted as needed.

Notice of Pre-Employment Screening Requirements

If you receive a job offer, please note all offers are contingent upon passing a pre-employment screening, which includes:

• Criminal background check
• Reference checks
• Drug Screening
• Health and Immunizations Screening
• Physical Demand Review/Screening

Equal Opportunity Employer Logan Health is an Equal Opportunity Employer (EOE/AA/M-F/Vet/Disability).

We encourage all qualified individuals to apply for employment. We do not discriminate against any applicant or employee based on protected veteran status, race, color, gender, sexual orientation, religion, national origin, age, disability or any other basis protected by applicable law. If you require accommodation to complete the application, testing or interview process, please notify Human Resources.

Welcome to One Sky Health

and thank you for your interest in becoming a part of our team. We believe that everyone who works at One Sky Health is a caregiver, regardless of the position. We provide competitive pay and a comprehensive benefits package. Our employees are motivated by our commitment to provide quality patient care for our community. Our people are everything. The amazing providers, employees, and volunteers at One Sky Health gift this organization with their innovation, knowledge, and compassion. Together, we're connecting our community to trusted, quality care and helping to improve lives every day. Do you dream of living and working in a beautiful area surrounded by stunning scenery and endless recreation? Are you ready to evolve your career while working alongside passionate, talented, brilliant people? Join our remarkable team and create positive patient experiences every day!