| Location | Asheville, North Carolina |
JOB SUMMARY:
Care Navigation will be part of MAHEC’s Population Health Administration embedded in primary care teams to ensure that patients receive the resources and services they need. The Care Navigator positions work with the clinical teams, behavioral health and community providers, to coordinate care and meet performance goals. The role’s primary responsibility is assistingpatients withneeded support servicesto achieve personal goals andoptimalhealth.
SPECIFIC RESPONSIBILITIES:
Engages and interacts with patients and/or family members to obtain and documentaccuratehistories, builds a trusting relationship, and implements a person-centered care plan.
Works to develop a strong relationship with identified patients and facilitates patient engagement during in person visits, group visits and virtually.
Uses motivational interviewing to gather pertinent clinical and psychosocial information from the patient and his/her friends and family as appropriate and coaching and support to achieve self-management goals.
Proactively identifies potential barriers to care plan,initiateinterventions with Providers(s), Nursing care managers, clinical social workers, and other caregivers to include alternative options to meet desired goals.
Communicateseffectively with appropriate caregivers to achieve targeted outcomes.
Documents activities, service plans, and results in an effective manner with EHR and care management platform
Refers patients and their families, who need assistance, to the appropriate educational resources regarding health care delivery and reimbursement, prescription drug programs, health and wellness programs, long term care insurance, asset and legal management, government programs, community agencies, public and private organizations, housing options, and other services, as appropriate.
Provides patient self-management support for priority chronic conditions or pregnancy and well childcare.
Collaborates with practice and organizational leadership to define workflows that meet contracted goals and requirements for screening, quality, outreach and care coordination to meet the goals of contracted requirements.
Utilizes a “Team Based Care” approach to ensure patients are appropriately screened for depression and social determinants of health.
Supports follow up on positive screening.
Usesdocumentation tools to support the patient goals, documentation of the care plan and closed loop referrals for health-related social needs.
Utilizes available tools to identify clinical gaps in care and communicate with the clinical team to support closing quality gaps and evaluate suspect conditions.
Ensures communication of the patient care coordination plan to members of the Primary Care team.
Serves as a liaison between care teams and community groups and foster and develop relationships with key contacts in those groups.
Collaborates with leadership to maintain partnerships with local community-based agencies and programs and support the success of the team in navigating these patient care needs.
Works with leadership to provide training on the workflows and documentation of health related social need to assure a plan for success in using the system to accept and respond to referrals.
Supports obtaining and developing education for clinical team to understand community partners in the counties served.
Supports Clinical Providers, Care Managers and Behavioral Health Consultants in coordinating community providers/services.
Utilizes a “team-based approach” to manage and assist in the care coordination process.
Seeks to eliminate confusion and duplication in services and supports quality, value- oriented care in coordination with patients, caregivers, providers, and appropriate community care partners.
Collaborates to maintain a resource database specific to patient’s local needs.
KEY COMPETENCIES:
Communication Skills
Effectively and respectably communicate with other individuals, whether it be a colleague, patient, or patient’s family member and appropriatelyenumerateinformation in a manner easily understood by all parties. We do this to foster a culture of understanding between all parties, especially in complex anddifficult situations, toultimately providethe best care possibletoour patients and their families.
Decision Making
Ability to make the mostappropriate decisionin a givensituation and thentakingthe next steps to ensureappropriateandtimelycompletion. This requires conflict resolution skills, critical thinking skills, confidencein your ability to make the right decision in most situations. This also includesabilityto prioritize your workday appropriately to ensure the most important tasks are completed on time.
HealthCare Knowledge
Having the drive to keep yourself abreast and up to date on the new breakthroughs in your area of expertise and communicating them to therest of the team, as appropriate. This also includes keeping up with your licensure and yearly training requirements within yourareaexpertisealong with MAHEC’sorganizational training. Finally, the ability to apply the depth of knowledgemaintainedand gained through this process in real life scenarios asappropriate.
Interpersonal Skills
Showing the ability to meetdifficult situationswith grace, professionalism, and understanding. Within your area of expertise, showing respect and showing empathy where appropriate with your colleagues, patients, and their familyat all times, even whenitsmost difficult to do so. This is done, in part, by effective listening, being your authentic self, showing responsibility and dependability, and being patient with others.
Organizational Values
Adherence to MAHEC’s founding principles and incorporating them every day. This includes, among others, having integrity and accountability, reverence for other cultures andequitablepractices,abilityto manage change, and displaying a clear understanding of organizational dynamics. Doing these things creates a culture where people want to dothebest for each other and gives personal ownership towards the goal of helping people in their time of need.
Problem Solving
Having an analytical mind and ability to work autonomously to solve complex problems that may arise. The wherewithal to think logically through a difficult problem and come toan appropriate resolutionfor a given issue. This helps to drive continuous improvement by thinkingthroughwhere we can improve in a novel way. Measures success by understanding where we are currently and where we want to go and then applying thosenew ideasto affect positive change.
SPECIFIED SKILLS
COMPUTER
Excellent skills in Microsoft Office including Word, Excel, PowerPoint, and database applications.
Care management platform experience preferred.
FOREIGN LANGUAGE
Spanish speaking skills preferred.
EDUCATION AND EXPERIENCE
MINIMUM QUALIFICATIONS:
Associate’s degree in health-related field, two years of undergraduate education in the social sciences or certification or license in a related field of study
PREFERRED QUALIFICATIONS:
Bachelor’s degree in social work or other Social Science, Community Health Worker, Certified Health Education Specialist (CHES) or Peer Support Specialist.Threeyears of experience in health care.
SCHEDULE:
COMPENSATION:
At MAHEC, we strive to equip all team members with Total Rewards (pay + benefits) to honor their service, support their health, manage their financial security, build their career, and thrive.
MAHEC is a qualifying employer for the Public Service Loan Forgiveness (PSLF) Program. Employees who meet federal requirements may be eligible to have remaining student loan balances forgiven after 10 years of qualifying payments while working full-time at MAHEC.
If you are interested in this role, and you have related experience and qualifications, we encourage you to apply or reach out to
AskTalent@mahec.net
for support in your job search process. You could be the talent we are seeking for this or other opportunitiesAll MAHEC employees and learners will be required to receive the Flu vaccine or have an approved exemption.
MAHEC does not provide employment-based US visa sponsorship, now or in the future. All new employees must provide valid, original I-9 documents on their first day of work.
MAHEC Talent Management is located at 121 Hendersonville Road, Asheville, NC 28803. Equal Opportunity Employer.