ACO PAC/TCM Navigator

Job Summary:

Centered in an Accountable Care Organization (ACO) department, this individual works in partnership with patients, families, nurses, physicians, and other qualified healthcare providers and clinical disciplines. Coordinates care for Medicare patients with chronic disease and manages effective care transitions for them within the continuum. Partners with the provider care team for successful annual preventative care visits to reduce the severity of chronic disease and avoidable acute illness. Provides effective clinical health coaching to assist patients with self-management of their chronic disease and life-style changes to mitigate health risk. Promotes effective partnerships and utilization of community resources. Facilitates a "shared goal model" within Artesia Healthcare Professionals and across settings to achieve coordinated high-quality care that is patient and family-centered.

ESSENTIAL FUNCTIONS:

• Responsible for other programs to include Transitional Care Management (TCM), Case Management initiatives, and coordinating efforts with the Post-Acute Care providers/facilities, including skilled nursing facilities and home health agencies.
• Determine if the post-acute admission into a skilled nursing facility is appropriate given a patient's clinical presentation and advise if other options, such as home with services, is an optimal alternative.
• Responsible facilitating access to post-care for patients that have a high Emergency Department utilization.
• Review documentation and/or assess a patient's clinical presentation and collaborate with the provider for optimal alternatives when advised.
• Coordinating with post-acute facilities to be apprised of the patient's condition and progress, including those receiving home health care, looking for:

• Any deviation from the standard of care for patients
• Patients being in the post-acute care setting and/or receiving services longer than expected
• Patients not receiving expected services
• Patients getting complications in the post-acute setting that puts them at risk for admission to ED and/or hospital
  • Coordinate discharge planning needs with post-acute facilities to ensure the patient has:
• Proper follow-up with the PCP and specialists
• Equipment for transition to home
• Home health services arranged, starting when the patient is discharged
• Care management support, including transitions of care
  • Coordinate with the Chronic Care Management (CCM) vendor to provide a team approach to the CCM patient population. This can include, but not limited to:
• Facilitating communication between the CCM vendor and the providers
• Care navigation for those patients that do not qualify for the vendor CCM program
• Timely and accurate documentation of CCM care plans, as needed.

ADDITIONAL RESPONSIBILITIES:

• As assigned

POSITION COMPETENCIES:

• Core Values consistent with a patient/family-centered approach to care.
• Demonstrates professional and effective written and verbal communication skills.
• Demonstrates understanding in use of IT resources and patient databases. Demonstrates a positive, respectful attitude and professional customer service.
• Acknowledges patients' rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPAA guidelines and regulations.
• Proactively acts as a patient advocate, responding with empathy and respect to resolve patient/family concerns.
• Recognizes and responds to opportunities for improvement.
• Demonstrates continual learning skills, effects change in approach to care based on established, evidence-based practice.
• Demonstrates professional practice behavior.
• Assists with mentoring/coaching of other care coordination team members.
• Cultivates effective partnerships, effectively collaborates with all practice providers (Physician, Nurse Practitioner, Physician Assistant and other licensed allied health team-members).

Risk Management/Quality Management/Safety: Cooperates fully in all Risk Management, Quality Management, and Safety Activities and Investigations.

MINIMUM POSITION QUALIFICATIONS:

• Current licensed Social Worker, Licensed Practical Nurse (LPN),
• Two years' experience in provider practice or clinic health setting preferred.
• Experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred
• Possesses strong clinical assessment and critical thinking skills necessary to develop a comprehensive plan of care appropriate to the patients complex medical, emotional and social needs.
• BLS certification required
• Attention to detail and accurate documentation.
• Ability to work in a high-volume caseload environment and deal effectively with rapidly changing priorities.
• Effective organizational, leadership, communication, education, collaboration, and counseling skills.
• Previous care coordination or annual wellness experience preferred.
• Experience with post-acute care facilities and the ability to mobilize community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred.
• Ability to speak a relevant second language - bilingual (English/Spanish) preferred.
• Previous experience with health IT systems and data reports preferred.
• Demonstrated ability to work constructively with all disciplines related to caring for patients within the community.

ENVIROMENTAL CONDITIONS: Work environment consists of daily patient contact, which may include exposure to blood, or other body fluids.