Lpn Nurse Navigator

The Nurse Navigator, LPN functions as the central point of contact for our Accountable Care Organization (ACO) and Population Health department at Griffin, coordinating and facilitating transition of care, chronic care management, and care management of our patients at Griffin Health.  The Nurse Navigator, LPN works in collaboration with the primary care providers, Nurse Navigator, RN and LPN, Community Health Workers and all members of the health care team.  They will manage assigned caseload to provide care coordination and outpatient interventions to improve the health and wellbeing of our patients.  The Nurse Navigator, LPN will work closely with Nurse Navigator, RN on the team to manage the complex patient cases and will work closely with a multidisciplinary team, provider offices, inpatient teams, and payers to identify target patient populations and coordinate care across multiple settings.

 ESSENTIAL FUNCTIONS:

• Collaborate in overseeing the practice’s chronic disease registries
• Work closely with Nurse Navigator, RN and Community Health Workers on their team to help manage daily patient outreach assignment and transition care management calls
• Manage chronic disease management cases of acute patient panel
• Assist with and facilitate transitions of care from inpatient settings such as hospital, rehabilitation facilities, and skilled nursing facilities to home
• Develop a comprehensive, collaborative care plan, based on a provider treatment plan, evidence-based chronic care guidelines, and patient/family goals for patients in the chronic disease registries, recent discharges, and those in care transition to promote adherence to physician/provider recommendations and instructions
• Assesses social determinants of health and work closely with Community Health Worker to provide resources to the patient to best manage their needs that contribute to health and wellbeing
• Provide individual patient/family education and self-management support that is appropriate based on language, cognitive abilities, literacy level, learning style, cultural norms, patient preference, readiness for change and resources available
• Provide education to patients regarding health conditions, nutrition, symptoms to report to PCP and specialists
• Collaborate in goal planning and care management with other team members
• Communicate changes in patient’s status appropriately with the care team and Nurse Navigator, RN for further follow up
• Perform an after-visit summary review with navigated patients when appropriate
• Identify barriers when treatment goals are not met, treatment plan is not being followed, or appointments are missed
• Identify patients who are overdue for visits, labs and referrals, contact patients and arrange for follow-up services as needed

EDUCATION: LPN License in CT required

EXPERIENCE: 

• LPN License
• 2 years of nursing experience in case management or home health preferred
• Previous experience working for an Accountable Care Organization, insurance company, managed care, home health and discharge planning preferred
• Ability to work with patients telephonically and coordinate care in the outpatient setting 

OTHER QUALIFICATIONS: Must be able to work collaboratively as a team member and have excellent interpersonal skills. Must be able to incorporate self-care and shared decision making in all aspects of beneficiaries’ care while exercising sound judgment in intervening with physicians and other clinicians when appropriate. Must be proficient using Microsoft Excel and able to learn quickly learn to use new computer software programs.

PHYSICAL DEMANDS/WORKING CONDITIONS: Ability to travel frequently to hospitals, skilled facilities, patient homes, and to other sites where patients receive care as indicated by patient need.

HOURS: 40 hours per week Monday through Friday. Office-based position in Derby, CT.

EOE/Minorities/Females/Vet/Disabled