Location: Port Jervis, New York
The ED Care Navigator is responsible for coordinating care to obtain desired health outcomes, improve self-care abilities, decrease cost of care, and provide extraordinary patient care in the process. The ED Care Navigator utilizes evidence-based medicine, data analytics and innovation in implementing care management principles to meet patients and their families' needs. This position understands and applies principles of population health management to identify patients with high-risk conditions and/or rising risk indicators and facilitates a plan of care that addresses such needs.
- Communicates and relates with individuals of all backgrounds and levels.
- Works with a multidisciplinary team and patients to develop, implement and monitor a comprehensive plan of care to prevent, mitigate and/or manage varied healthcare conditions.
- Identifies high-risk patients and creates a plan of care to address their vulnerable conditions.
- Navigates identified patients to primary and preventative care by assisting patients in obtaining a PCP and/or enrollment in chronic disease management care.
- Coordinates follow up appointments with PCP and community providers.
- Utilizes the EMR, PSYKES and Healthify for care transitions and discharge summary purposes.
- Creates documentation and adheres to workflows for eligible patients needing Health Home services and/or active Health Home enrollment.
- Serves as a member of Ambulatory Care Management team and performs appropriate department functions by attending meetings and adhering to documentation requirements.
- Assesses patient/family abilities to self-engage and develops individualized patient/family education plan focused on development of self-management skills based on System's standard care protocols.
- Advocates the completion of living wills and advance care planning.
- Communicates clear, complete and accurate documentation in a health record to ensure that all those involved in a client's care has access to information upon which community interventions are necessary.
- Updates plan of care timely to ensure all members of the care team have timely information regarding the patients' status.
- Performs other duties as assigned.
Current New York State RN licensure or licensed Social Worker (LCSW, LMSW or LMHC). Case/Care management certified or knowledge of national care management standards and community resources preferred. 5+ years of acute care/ambulatory care experience in the emergency department working with vulnerable populations preferred with ability to navigate in electronic medical records required (Epic).
Bachelor's degree required.
If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.
Bon Secours Charity Medical Group
Bon Secours Charity Medical Group, part of Bon Secours Charity Health Systems (BSCHS), a regional network of more than 120 primary care physicians and specialists from a broad array of medical specialties. BSCHS, a member of WMCHealth Network, includes Good Samaritan Hospital in Suffern, NY, Bon Secours Community Hospital in Port Jervis, NY and St. Anthony Community Hospital in Warwick, NY.