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. The Care Navigator acts as a resource to assist patients in navigati
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
Brown University Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status. Brown University Health is a VEVRAA Federal Contractor.
Location: Brown Health Medical Group Primary Care USA: RI: Providence