Care Gap & Chronic Care Nurse Navigator

Description

POSITION SUMMARY

Care Gap & Chronic Care Nurse Navigator is a position involving the provision of exceptional telephonic care coordination to patients with chronic conditions. This role will be a clinical expert, a patient advocate, and a key educator.

REPORTING RELATIONSHIPS

This position reports to the Chief Nursing Officer.

ESSENTIAL JOB DUTIES AND FUNCTIONS

While living and demonstrating our Core Values, the Care Gap & Chronic Care Nurse Navigator will:

• Conduct comprehensive monthly outreach to a dedicated panel of at least 40 Chronic Care Management (CCM) patients, assessing health status, evaluating treatment adherence, and providing health coaching.
• Leverage EMR reports and registries to identify outstanding preventative health gaps (e.g., immunizations, diabetic eye/foot exams, cancer screenings) and facilitate necessary care.
• Collaborate with patients, primary care providers, and the care team to establish, implement, and update personalized care plans for complex chronic conditions (e.g., diabetes, hypertension, COPD, CHF).
• Perform timely post-discharge and post-ED outreach to reconcile medications, review discharge instructions, and schedule follow-up appointments to prevent avoidable readmissions.
• Serve as the central point of contact for patients, coordinating appointments, diagnostic testing, specialist referrals, and pharmacy services.
• Maintain accurate, timely, and complete documentation of all patient encounters, interventions, and care plan modifications within the Electronic Medical Record (EMR).
• Ensure all care coordination and CCM time-tracking activities strictly adhere to Centers for Medicare & Medicaid Services (CMS) guidelines and quality standards.

Requirements

• Meet The Wright Center for Community Health and its affiliated entity The Wright Center for Graduate Medical Education EOS© People Analyzer Tool
• Buy in and experience working in the EOS® model (strongly preferred)
• Mission-oriented; represents the enterprise in a professional manner while demonstrating organizational pride
• BS Degree in Nursing
• Registered Nurse in the state of Pennsylvania
• Previous experience in a health center setting a plus
• BLS Certification
• Experience with electronic health record, Medent a plus
• Ability to work as part of a care team
• Excellent communication skills
• Commitment to process improvement and quality