RN Care Navigator - Hybrid - Stuart, FL

About the position

The RN Care Navigator plays a crucial role within an interdisciplinary care team, focusing on proactively engaging high-risk patients and implementing targeted interventions to address their social needs and enhance access to healthcare. This hybrid position involves a combination of fieldwork and home-based responsibilities, requiring a deep understanding of socio-economic factors affecting patient engagement and health outcomes. The Care Navigator will guide care coordination efforts, manage clinical escalations, and work closely with patients to develop comprehensive care plans that address their unique needs.

Responsibilities

• 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 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 the interdisciplinary team.
• Support patients' self-determination, motivate patients to meet the health goals they have identified.
• Refer patients to necessary services and supports.
• 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.

Requirements

• Registered Nurse (RN license)
• Minimum of 4 years of experience working in human services and navigating community-based resources
• Bilingual in English and Spanish
• Advanced clinical acumen
• Excellent organizational skills
• Strong interpersonal and relationship building skills
• Critical thinking and problem-solving capabilities

Nice-to-haves

• Familiarity with state Medicaid guidelines and application processes
• Experience working with patients with behavioral health conditions and substance use disorders
• Prior experience conducting home visits and knowledge of field safety practices

Benefits

• Health benefits effective day 1
• Paid time off, holidays, volunteer time and jury duty pay
• Recognition pay
• 401(k) retirement savings plan with employer match
• Tuition assistance
• Scholarships for eligible dependents