Patient Navigator-Emergency Liaison

Hawaii Island Community Health Center

Job Title: Patient Navigator-Emergency Liaison

Supervised By: RN Care Coordination Manager

IPOSITION FUNCTION SUMMARY

Under the direct supervision of the RN Care Coordination Manager, the Patient Navigator- Emergency

Liaison (PN-EL) is responsible for providing transitional support for Hawaiʻi Island Community Health Center (HICHC) patients utilizing the emergency department. The PN-EL will facilitate the dynamic, interactive, collaborative, and interdisciplinary process of assessment and evaluation of the healthcare and social needs of patients and their natural supports relating to emergency episodes. Transitional planning includes planning and brokering of necessary services and resources identified based on the patient’s condition. In addition, PN-EL’s bridge communication between HICHC, the hospital, and payors.

II.ESSENTIAL DUTIES AND RESPONSIBILITIES

This position may have various work assignments within HICHC. This description is intended to be generic in nature, and as such it does not detail all duties and responsibilities of the job assignment. Various duties, responsibilities and accountabilities may be assigned to an incumbent in this position depending on clinic needs, and may include but not be limited to the following:

• Reviews emergency department admissions Monday-Friday via reports from Hawaiʻi Health Information Exchange (HHIE), clinic, hospital, or payor.

• Supports continuity of care through bidirectional sharing of clinical information between hospital and clinic setting.

• Supports the registration of new patients in completing new patient packets and registering into the electronic health record.

• Provides assessment and evaluation of patient’s health and social needs; assesses eligibility for HICHC programs (i.e., Chronic Care Management); completes corresponding intake processes; and messages programs for follow up and /or schedules appointments

• Partners with the patient to address the non-clinical barriers that patients face, with a focus on the social factors that negatively affect the patient’s health (i.e., food security).

• Documents all service contacts on a timely basis including face-to-face, collateral and networking contacts, correspondence and maintains the case records in accordance with agency and regulatory standards and requirements.

• Participates in interdisciplinary team meetings with HICHC team members involved in the patient’s care.

• Supports discharge appointment scheduling leveraging knowledge of both systems to schedule with the most appropriate provider based on linguistics, patient preferences, and provider practice specialization.

• Participates in interdisciplinary meetings or informal check-ins with hospital and HICHC teams; develops relationships with staff and providers in both settings while understanding the general standard operating procedures of both organizations.

• Coordinates face to face meetings with care coordination manager, aligns schedule to meet patients and ER staff in person when needed.

• Leverages EPIC EHR to generate predictive reports of emergency department high utilizers (HU); defines HU cohorts by payor; keeps registry of these individuals; assesses needs and refer to appropriate services in an effort to prevent emergency services intervention.

• Conducts and participates in meetings with payor quality and care coordination teams; communicates regularly to collaborate on patient care, link to care coordinators as needed.

• Provides support in the overall operation by acknowledging, adhering to, and implementing overall organizational and medical policies and operating procedures of HICHC.

• Facilitates referrals for clinically indicated services outside of the organization (e.g., social services such as housing assistance, vocational rehabilitation, mental health specialty care, substance use treatment).

• Builds relationships with community-based organizations that work on the upstream factors that impact patients, such as housing, benefits, food resources, etc.

• Supports social care needs of Chronic Care Management (CCM) and Transitional Care Management (TCM) patients when possible.

• Supports HICHC in meeting quality measures associated with hospital emergency department discharge criteria.

• Meets regularly with the immediate supervisor for professional development, while reviewing, and processing the provision of services.

• Performs other duties as assigned by the supervisor which are consistent with the position and in compliance with HICHC policies and procedures.

III.POSITION SPECIFICATIONS Requirements of Position

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.

The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience

• High School graduate or GED certificate and two years of health service experience required.

• LPN Nursing degree preferred.

• Strong understanding of local community resources and social services agencies.

Certification and Licenses

• Valid Hawaiʻi driver's license and current auto insurance required.

• Required with LPN Nursing degree; Current Nursing license (LPN) for the State of Hawaiʻi and current BLS certification. Documentation of education, experience, licensure and certification is required and must be maintained; incumbent must be insurable under the policies and requirements of HICHC.

Knowledge, Skills and Abilities

• Must be sympathetic and compassionate to the client’s issues, while maintaining professional boundaries.

• Must be able to work as part of an interdisciplinary team.

• Ability to prioritize and balance tasks in a high paced environment, with autonomy.

• Problem solving skills—the individual identifies and resolves problems in a timely manner, gathers and analyzes information skillfully and utilizes management appropriately.

• Displays a high level of professionalism, ethical decision-making skills, and emotional stability.

• Technological aptitudes - the individual is adept at utilizing Microsoft Office applications, video teleconferencing platforms, and is able to learn new skills in adjacent electronic documentation systems.

• Able to travel to and from clinic locations and in the community, with a valid driver's license, working vehicle and current insurance.

Language Skills

• Ability to read and interpret documents such as patient records, operating and maintenance instructions, procedure manuals, etc.

• Ability to write at an above average level of competence, including internal reports and memoranda.

• Ability to communicate with diverse groups of people to include staff and providers and patients.

• Ability to communicate effectively with patients and their families to make their visit a pleasant experience.

• Sensitivity to the multicultural nature of the service area population and may be required to communicate in another language.

Physical Requirements

• Prolonged periods of sitting at a desk and working on a computer.

• Prolonged periods of standing, bending and reaching.

• Must be able to lift up to 20 pounds at times.

Personal Characteristics

Personal characteristics include: a team player, high integrity, multitasker, communication and customer relations skills, regular work attendance, courteous and friendly, able to work well with diverse groups of people, gain and maintain the respect of others, accept HICHC mission and values.

Confidential and Sensitive Information

Because the employee has access to personal and professional data regarding individual employees and their families, personal data regarding individual patients and the families, and/or sensitive company financial data, an essential job result is the maintenance of a high level of confidentiality of the information processed by the employee. Violation of this confidence may result in disciplinary action, up to and including termination of employment.