Overview RN Case/Care Manager role at CenterWell Senior Primary Care. Working within an interdisciplinary care integration team (CIT), the Care Navigator – Registered Nurse is responsible for proactively engaging patients and implementing targeted interventions to address whole person health and increased access to care. The Care Navigator – Registered Nurse will provide guidance and oversight of care coordination efforts to other members of the team, and manage 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 ideally includes prior care or case management work with transitions of care and high-risk patient management programs in partnership with PCP care team members including community health workers, pharmacists, and behavioral health specialists.
Duties And Responsibilities Conduct Transitions of Care Management for a subset of the patient population, including hospital, obs, and post-acute care 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 holistic 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 support across the interdisciplinary team
This may include and 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 CIT Team Meetings when indicated
Assess patient’s family and caregiver system, and conduct family meetings with patient and family when needed
Participate in creation and facilitation of team training content
Participate in and lead CIT 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
Perform all other duties and responsibilities as required
Required Qualifications Registered Nurse (RN license)
Minimum of 4 years of experience working in human services and navigating community-based resources
Preferred Qualifications Experience working in care/case management
Prior value-based care experience and working with complex Senior populations
Experience working effectively within interdisciplinary teams
Bilingual in English and Spanish or Creole with the ability to speak, read and write in both languages without limitations nor assistance
Skills/Abilities/Competencies Required Advanced clinical acumen
Ability to multi-task in a fast-paced work environment
Flexibility to fluidly transition and adjust in an evolving role
Excellent organizational skills
Advanced oral and written communication skills
Strong interpersonal and relationship building skills
Compassion and desire to advocate for patient needs
Critical thinking and problem-solving capabilities
Working Conditions This role has a mobile presence and requires regular onsite engagement with the care team to assigned clinics to see patients in person and collaborate with care team members.
Workstyle: Hybrid - Combination in clinic and working remotely/virtually.
Location: Must reside in Phoenix metro
Hours: Must be able to work a 40-hour work week, Monday through Friday 8:00 AM to 5:00 PM, incremental time may be requested to meet business needs.
Tuberculosis (TB) screening: This role is considered member facing and is part of Humana’s Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
Role Driver's License, Reliable Transportation, Insurance This role is part of Humana's Driver safety program and therefore requires an individual to have:
a valid state driver's license,
carry insurance in accordance with the state minimum required limits, or $25,000/$25,000/10,000 whichever is higher
and a reliable vehicle.
Scheduled Weekly Hours 40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$71,100 - $97,800 per year
Description Of Benefits
Humana, Inc. and its affiliated subsidiaries offer competitive benefits that support whole-person well-being. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off, short-term and long-term disability, life insurance and many other opportunities.
About Us
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 integrated care teams 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 part of Humana Inc., 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. 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.
Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements.