Description Summary: The Registered Nurse Navigator Population Health Senior is accountable for coordinating and managing a designated patient caseload patient care across the healthcare continuum. This role focuses on improving health outcomes for populations by implementing evidence-based practices, promoting preventive care, and ensuring patients receive appropriate and timely interventions. Registered Nurse Navigator Population Health Senior will work collaboratively with ACO and CIN Network providers, patients, and their families across CHRISTUS Health ministries to develop and implement individualized care plans. The RN Navigator Senior will manage the length of service, promote efficient utilization of resources, and ensure that a well-organized and safe plan of care is established for every patient. Registered Nurse Navigator Population Health Senior will provide leadership and guidance to other team members, acting as mentors. Responsibilities: Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders. Team Leadership: Mentor, train, and support the team of nurse case managers, ensuring high-quality care and adherence to best practices. Care Coordination: Manage and coordinate care for patients with complex medical needs and those at high risk for hospitalization. Patient Assessment: Conduct comprehensive assessments to identify patient needs, barriers to care, and social determinants of health. Care Planning: Develop and implement individualized care plans based on patient assessments, clinical guidelines, and patient preferences. Patient Education: Provide education and support to patients and their families on disease management, medication adherence, and healthy lifestyle choices. Monitoring and Evaluation: Track patient progress, adjust care plans as needed, and evaluate outcomes to ensure effective care delivery. Team Collaboration: Foster a collaborative environment where nurses feel comfortable seeking advice and sharing ideas. Work closely with healthcare providers, social workers, and community resources to ensure a holistic approach to the patient. Leadership Collaboration: Collaborates with leadership to design market-specific strategies, data analytics, and create action plans that will reduce acute and post-care utilization. Solicits/shares feedback with leaders on team-based focus with attention given to success and opportunities to improve the one care team culture and collaboration on high-risk patient management. Effectively prioritizes patients with the market leaders who benefit the most from care management programs. Quality Improvement: Participate in and lead quality improvement initiatives with the team of nurses to enhance patient care and population health outcomes. Compliance: Ensure compliance with all regulatory requirements, organizational policies, and best practices in case management. Training and Development: Coordinate and assist with associate onboarding. Provide ongoing training and professional development opportunities for the care management team. Must have knowledge of discharge planning, case management, performance improvement, and managed care reimbursement. Must understand pre-acute and post-acute levels of care and community resources. Must have the ability to work independently and exercise sound judgment in interactions with physicians, payors, patients, and their families. Must have the ability to lead and motivate a team. May be asked to assist with special projects. Performs other duties as assigned. Job Requirements: Education/Skills Bachelor's degree in nursing (BSN) required Experience 3 years of clinical nursing experience required 5 years of case management experience required Experience working in primary care value-based care organization is required Strong clinical assessment skills and experience required Excellent communication and interpersonal skills required Proficiency in keyboarding, EHR systems, and knowledge of population health management principles are required Licenses, Registrations, or Certifications RN license in the state of employment or compact is required One of the following certifications is required Certified Case Manager (CCM) by CCMC Nursing Case Management Certification (CMGT-BC) by ANCC In accordance with the CHRISTUS Health License, Certification and Registration Verification Policy, all Associates are required to obtain the required certifications for their respective positions within the designated time frame. Work Schedule: 8AM - 5PM Monday-Friday Work Type: Full Time
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