This position provides comprehensive care coordination, supporting a holistic and coordinated approach across the continuum of care. This position assists with informed decision-making; collaborating with a multidisciplinary team to allow for timely screening, diagnosis, treatment and increased supportive care throughout the patient experience. This position provides individual assistance to patients, families and caregivers to help identify and overcome barriers which may hinder quality medical and psychosocial patient care.

• Collaborates with members of the healthcare team to coordinate an evidence-based plan of care.
 
• Identifies new and established patients with a diagnosis that requires navigator services.
 
• Facilitates scheduling of appointments for clinical consultations and support services.
 
• Provides emotional and educational support for patients and families.
 
• Assists patients to make informed decisions and participates in patient education by assisting patients in understanding their diagnosis, treatment options, and available resources while serving as patient advocate on the multidisciplinary team.
 
• Conducts initial and ongoing comprehensive needs assessments of patients and families and encourages participation in the care plan.
 
• Documents in the electronic health record, as indicated, all interventions and clinical changes using established care guidelines.
 
• Reviews results of care plan and readjusts priorities as patients’ status changes.
 
• Assists transitions patients from one phase of care to the next, including self-management and independence in self-care.
 
• Follows patients throughout the care continuum, including inpatient admissions, collaborates with inpatient care management team. Follows an intervention plan from the time of patient referral, coordinates care among team members, reviews patients’ disposition from care, provides patient information and education, assists patients in obtaining a second opinion, follows patients during treatment, and evaluates care and changing priorities.
 
• Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of Foundation Health with an excellent service experience by consistently demonstrating our core service behaviors each and every day.

• High school diploma/GED or equivalent working knowledge.
• Requires the knowledge typically achieved with the completion of a patient navigator education/certification program from an accredited organization, association, or university. Certification required within twelve (12) months of hire/transfer depending on specialty.
• Requires a proficiency level typically achieved with two (2) years clinical experience.
• Requires excellent organizational skills and clinical knowledge regarding specialty care services, as well as care coordination of services, legal and financial aspects of diagnostic services and health services in specialty area.
• Requires effective communication and writing skills, good time management skills and knowledge of word processing and database software applications. Requires the ability to teach both clinical and non-clinical personnel regarding care and diagnostics services. Also requires a good understanding of process improvement.

Preferred Qualifications 

• Certified Health Education Specialist (CHES), Master Certified Health Education Specialist (MCHES) or related certification preferred.
• Prior Case Management experience preferred.
• Additional related education and/or experience preferred.