Working within an interdisciplinary care team, the Care Navigator is responsible for proactively engaging patients identified as high-risk and implementing targeted interventions to address social needs and increase access to care. The Care Navigator will provide guidance and oversight of care coordination efforts to other members of the team, and handle clinical escalations as indicated.

This role has a mobile presence, involving travel to patients’ homes, treatment facilities and community-based settings, and assigned clinics to facilitate and foster connections.

Major Duties and Responsibilities

• Conduct Transitions of Care Management for a subset of the patient population, including ER and hospital follow ups
• Provide triage guidance and supportive consultation to other team members, handling escalated complex cases
• Develop care plans leveraging 5Ms Geriatric best practice framework
• Develop a wholistic view of patient needs related to Social Determinants of Health
• Identify existing barriers to engagement with necessary resources and supports
• Provide education around maintenance of chronic health conditions, as well as available options for behavioral care and social support
• Serve as liaison between the patient and the direct care providers, assisting in navigating both internal and external systems
• Initiate care planning and subsequent action steps for high-risk members, coordinating with interdisciplinary team
• Supporting patients’ self-determination, motivate patients to meet the health goals they have identified
• Refer patient to necessary services and supports

Required Qualifications

• Registered Nurse (RN license)
• Minimum of 4 years of experience working in human services and navigating community-based resources

Job Type: Full-time

Pay: $80,000.00 - $90,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Parental leave
• Vision insurance

Medical specialties:

• Geriatrics
• Primary Care

Physical setting:

• Acute care
• Clinic
• Hospital
• Inpatient
• Long term care
• Nursing home
• Rehabilitation center

Standard shift:

• Day shift

Supplemental pay types:

• Yearly bonus

Weekly schedule:

• 5x8
• Monday to Friday

Experience:

• Human Services: 4 years (Required)

License/Certification:

• RN License (Required)

Ability to Relocate:

• Belle Glade, FL 33430: Relocate before starting work (Required)

Work Location: In person