Job Information
University Medicine Care Navigator in East Providence, Rhode Island
SUMMARY:
The Care Navigator (CN) is responsible for helping persons living with complex illness and their caregivers navigate and access health care, home and community-based services, and adapt to the challenges of complex illness. The CN collaborates with physicians, nurse practitioners, social workers, and case managers in an integrated approach to care management and community outreach. The CN supports innovative clinical programs such as Guiding an Improved Dementia Experience (GUIDE). The CN provides social support and informal counseling, utilizes motivational interviewing, applies condition-specific care management protocols, advocates for individual and community health needs, and provides introduction and assistance with accessing resources.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
Consistently applies the Brown Medicine values of patient care priority, dignity, collaboration, integrity, equity, inclusion, respect for diversity, and quality in support of the Brown Medicine mission to deliver compassionate, high-quality patient care, research excellence and outstanding physician education in a culturally sensitive environment. Is responsible for knowing and acting in accordance with the Brown Medicine Compliance Program and Code of Conduct.
Consistently practices the Brown Medicine Customer Service Standards.
Responsible for establishing trusting relationships with patients and their families while providing general support and encouragement.
Work collaboratively with the Interdisciplinary Care Team by clearly and accurately presenting to the team and consulting the team and its individual members when appropriate.
Perform a person-centered (and caregiver centered) assessment of strengths, needs, goals, preferences, and desired outcomes, including understanding cultural and linguistic factors and unmet social determinant of health (SDOH) needs.
Participate in the development of a care plan including patient-driven goal setting and an action plan
Provide ongoing follow-up, motivational interviewing, and goal-setting with persons living with complex illness and their families.
Provide health education, teach self-advocacy and behavioral change techniques, and use condition-specific care management protocols, for example, when helping persons living with dementia and their caregivers cope with the effects of dementia in meeting the person-centered treatment goals.
Monitor a panel of persons living with complex illness, by maintaining follow-up contact with persons living with complex illness and their care partners via telephone, video, and in-person visits consistent with contact frequency algorithms and bringing information about changes in the patient to the care team.
As appropriate, observe and assess/reassess instrumental and basic activities of daily living skills and teach caregivers methods to adapt to incapacities such as adjusting daily routines.
Identify unmet care needs and provide referrals for services and support to community agencies as appropriate, acting as a patient advocate and liaison between the patient/family and community service agencies to facilitate accessing those services.
Maintain knowledge of community resources relevant to the target audience of the care navigation program.
Assist in the development of advance directives
Work collaboratively with staff, clinicians, students, and trainees at all levels of health professions training.
Document patient information and encounters in the electronic health record according to standards.
Attend regular staff meetings, trainings and other meetings, as requested.
Perform other duties as assigned.
KNOWLEDGE, SKILLS & ABILITIES REQUIRED:
Good organizational skills to handle multiple priorities while remaining professional and calm.
Ability to work with many diverse people, including individuals with Alzheimer’s disease and related dementias, serious mental illness, behavioral challenges, and other disabilities.
Knowledge of Care Navigation in general and specific to the condition in order to implement the principal duties or an ability to learn these competencies.
Effective telephone skills.
Ability to make constructive suggestions on workflow or system efficiency and effectiveness.
Ability to work independently and achieve an appropriate balance of self-direction and teamwork.
Ability to prioritize and follow through on commitments.
Ability to perform routine components of the Care Navigator role with minimal supervision.
Ability to work at a high-volume level of accuracy.
EDUCATION AND EXPERIENCE:
Experience and Skill Requirements: The following experience and skills are considered essential:
Written and oral fluency in English is required. Proficiency in Spanish will be viewed favorably.
Experience working in a multi-cultural setting.
Experience working in a community-based setting for at least 1 to 2 years preferred.
Basic computer skills required; electronic medical record (EMR) experience preferred.
Understand the community served, community connectedness. Persons with lived experience may be preferred.
Good communication skills, such as listening well, and using language appropriately.
Ability and willingness to provide emotional support, encouragement and motivation to persons living with complex illnesses and their caregivers.
Education Requirements: The following education requirements are considered essential:
High school graduate or equivalent required;
Successful completion of formal training and/or certification as a Community Health Worker or Navigator is preferred.
Medical terminology and/or background preferred.
WORKING CONDITIONS AND PHYSICAL REQUIREMENTS:
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The physical requirements described here are representative of those that must be met by the essential functions.
While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time, talk, and hear. The employee is occasionally required to stand, walk, and use hands to operate a standard computer keyboard. The employee may occasionally lift and/or move up to 25 pounds. Vision requirements include: close vision, distance vision, depth perception, and the ability to adjust focus. Ability to read multiple handwritings.
The work includes home visits and the candidate must have an ability to transport themselves to the home.
INDEPENDENT ACTION:
Must be able to respond to questions from patients/caregivers, conferring with care team members as needed for questions outside of scope of knowledge (e.g medical).
Coordination of access to support services and community resources
SUPERVISORY RESPONSIBILITY:
None