Divisional RN Care Navigator- Remote Houston, TX

About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. Our unique care model focuses on personalized experiences, taking time to listen, learn and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patient’s well-being. About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation’s largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first – for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one.

Working within an interdisciplinary care team, the Care Navigator is responsible for proactively engaging patients identified as high-risk and implementing targeted interventions to address social needs and increase access to care. The Care Navigator will provide guidance and oversight of care coordination efforts to other members of the team, and handle clinical escalations as indicated. This role requires an understanding of how socio-economic stressors can impact ability to engage in healthcare and subsequent health outcomes. Experience will ideally include prior work with patients with behavioral health diagnoses, as well as in navigating local community-based resources and benefit applications. This role has a mobile presence, involving travel to patients’ homes, treatment facilities and community-based settings, and assigned clinics to facilitate and foster connections.

Conduct Transitions of Care Management for a subset of the patient population, including ER and hospital follow ups Provide triage guidance and supportive consultation to other team members, handling escalated complex cases Develop care plans leveraging 5Ms Geriatric best practice framework Develop a wholistic view of patient needs related to Social Determinants of Health Identify existing barriers to engagement with necessary resources and supports Provide education around maintenance of chronic health conditions, as well as available options for behavioral care and social support Serve as liaison between the patient and the direct care providers, assisting in navigating both internal and external systems Initiate care planning and subsequent action steps for high-risk members, coordinating with interdisciplinary team Supporting patients’ self-determination, motivate patients to meet the health goals they have identified Refer patient to necessary services and supports This field may include but is not limited to: assistance with transportation, food insecurity, navigation of and application for benefits including, Medicaid, HCBS, working to reduce costs associated with prescription medications, organizing schedules of follow up appointments, alleviating social isolation Lead Interdisciplinary Team Meetings when indicated Assess patient’s family system, and conduct family meetings with patient and family when needed Participate in creation and facilitation of team training content Conduct group psychoeducation and support groups within the Center Perform all other duties and responsibilities as required Participate in and lead interdisciplinary review of and coordination around complex patients Maintain patient confidentiality in accordance with HIPAA Document patient encounters in medical record system in a timely manner Follow general policies related to fire safety, infection control and attendance