Healthcare Navigator, RN

Thank you for expressing your interest in pursuing a career with Valley Medical Group. We are a provider-owned, multi-specialty group. We proudly serve a diverse community of over 55,000 patients at four locations throughout the Pioneer Valley.

 Valley Medical Group is looking for a Healthcare Navigator, RN to join our team supporting our patients. This position is based in our Greenfield Health Center and supports all of Valley Medical Group. If you are looking for a dynamic environment, this is your opportunity! 

Position: Healthcare Navigator, Registered Nurse

Location: Greenfield, MA

Hours: 40 hours, Monday-Friday generally between 9:00am – 5:00pm. Hours may vary depending on department needs. Exact schedule to be discussed at time of interview.

As a Healthcare Navigator, you will be responsible for managing Valley Medical Group patients needing care management, disease management, supporting transitions in care and coordination of services to optimize patient care.

You will work collaboratively with the multi-disciplinary team, facilitating coordination of care, supporting patients to navigate follow up care needs and improve patient outcomes and utilization.   Care management provided to patients includes but is not limited to medication reconciliation, assisting patients connecting with specialists, community resources and service, coaching, providing health reminders and education, face-to-face visits, home visits if necessary, communication thru multiple methods (phone, text, other technology in use) and addressing social barriers to optimal health.

 The Healthcare Navigator collaborates with VMG clinical leaders to support innovative care models for coordinating with primary care in addressing population health needs.

 The Healthcare Navigator will be a role model for Valley Medical Group core values of caring, respect, integrity and teamwork, with a commitment to patient first focus and a passion for the delivery of high-quality care.

Job Responsibilities:

• Timely identification of patients needing care management services, transition in care support, and/or high risk.
• Support patients with transitions of care from any setting including hospital, skilled nursing facility and Emergency Departments. Complete assessments to determine individual patient needs with the transition and develop appropriate plan of care, including review of discharge instructions, medication reconciliation, consideration of testing and/or consultations to be completed.  Provide patient teaching/coaching as needed and the same of Healthcare Resource Coordinators
• Facilitate transitions of care (TOC) for VMG patients, utilizing a variety of tools including:  Athena EHR, PING, High risk patient lists, quality data, Hospital System secure texting platforms and others.
• Advocate for patients and their families, ensuring their needs and preferences are considered in the care planning process.  Serve as a liaison between patients, healthcare providers, and other relevant stakeholders.
• Ensure that patients are informed and empowered to actively participate in their healthcare decisions. Assist patients in understanding and adhering to their care plans.
• Educate patients and their families about their medical conditions, treatment options, and self-care strategies. 
• Collaborate routinely with all members of the care team to keep them informed and communication open and to coordinate patient care services, appointments, and follow-up plans. Participate in primary care huddles and complex care coordination. Coordinate with external providers for high-risk patients and transitions of care.
• Identify and connect patients with appropriate healthcare and community resources, such as support groups, financial assistance programs, and transportation services.  
• Maintain accurate and detailed documentation of patient interactions, care plans, and resources provided to patients.
• Support Advanced Primary Care Management (APCM) services by participating in care plan management, outreach and communication with high risk patients.
• Attend hospital and Skilled Nursing Facility (SNF) care management meetings as needed in person and/or virtually.
• Conduct home visits for patients when appropriate.
• Participate in patient triage activities when required by patient need.
• Support VMG clinical and quality initiatives including, monitoring performance of key measures as defined.  
• Ensure implementation, and adherence to departmental and organizational policies and procedures. Contributes to development of policies in areas of expertise.
• Attend all required meetings and participate in projects and committees as requested.  
• Ensure compliance with state, federal, and local regulations, guidelines and accreditation agencies.  
• Oversee daily operations for the Health Pathways Care Management Program, including staff assignments/schedules, supports team development, orientation, and training.  
• Provide ongoing feedback to support growth and development and performance evaluations.
• Other responsibilities and duties as assigned.

Required Qualifications: 

• Graduate of an accredited school of nursing and licensed as a Registered Nurse in the state of Massachusetts
• Current CPR certification (or commitment to obtain within three months of employment)
• Current MA Driver’s license
• Strong clinical assessment and decision-making skills
• Experience in navigating healthcare systems, patient advocacy and understanding of medical/social services
• Experience in care coordination, case management, and patient navigation
• Excellent communication and interpersonal skills, establishing and maintaining effective working relationships with patients and families, clinical staff, teams and members of the community
• Ability to work independently and collaboratively in a fast-paced environment
• Excellent skills and proficiency with electronic medical records (EMR), care management platforms, and other IT solutions used to support work
• Understanding of transitions of care workflows and population health strategies
• Travel to other sites including Valley Medical Group Health Centers, hospital facilities, skilled nursing facilities or patient homes as needed 

If you do not meet all of the preferred qualifications, we strongly encourage you to apply and/ or inquire. We often have multiple open positions and could consider you for another opportunity with our organization.

Valley Medical Group offers: 

• Medical, Dental & Vision Plans
• 401(k) Plan with Company Match
• Health Savings Account & Flexible Spending Account
• Generous Paid Time Off 
• 7 Paid Holidays 
• Company-Paid Long-Term Disability Insurance
• Company-Paid Life Insurance 
• Voluntary Life, Accident and Critical Illness Insurance Options
• Company Wellness Program 
• Employee Assistance Program
• Free On-Site Parking

We Value Employee Engagement and Inclusive Practices

Valley Medical Group (VMG) seeks to recruit, develop, and retain the most qualified workforce from a diverse candidate pool. We strive for every VMG staff person and provider to feel valued and be treated fairly, respectfully, and with dignity. We expect our employees to conduct themselves in a professional manner that promotes equal opportunity and prohibits unlawful discriminatory practices, including bias and harassment. 

Fostering inclusion and belonging among our employees is critical to our success in providing high-quality patient care rooted in evidence-based practices and health equity. We have several initiatives that prioritize the employee experience, from an annual assessment of employee engagement to staff recognition events, various feedback mechanisms, and committees that promote an inclusive workplace.