The Patient Navigator case manages individual program participants to reduce hospital readmissions and length of stay, improve quality and outcomes of care, and improve satisfaction for identified patients, working as part of an interdisciplinary medical home case management team to achieve the patient goals.

The Patient Navigator liaisons between numerous community programs, hospital staff and other professionals to manage patients’ needs and is a bridge between many aspects of patient care and quality improvement in the operations of the program

Patient contact or interventions may occur in the hospital, clinic, or community settings to meet the physical, psychosocial, or administrative needs of the patient utilizing applicable hospital, clinic, government, and community resources.

Case manages individual patients to reduce hospital readmissions and length of stay, improve quality and outcomes of care, and improve satisfaction for identified patients.

Works as part of an interdisciplinary medical home case management team to understand the patients’ physical, psychosocial, and administrative needs, assist with planning for patients both inpatient and outpatient, and to achieve patient goals.

Develops an effective working relationship with the patient and caregiver through engagement, collaboration, advocacy, decision making and problem-solving activities

Liaisons between numerous community programs, hospital staff and other professionals to manage patients’ needs and functions as the bridge between many aspects of patient care and quality improvement in the operations of the program.

Effectively communicates and navigates systems to include health care, social services, education and community resources to assure patients access and appropriate use of these services.

Works with patients to empower them to become an active participant in their health care, identifying challenges and resources to help clients solve their problems with the goal of educating the patient/family/others to navigate the health care system and community resources.

Works in community and hospital settings, or other designated settings, to ensure that the patients’ needs are properly identified. This will include, but not limited to, home visitations, hospital visits, ED visits, other medical appointments and all other approved locations to work efficiently with the patient to provide stability.

Completes assessments on patients to assist with identifying behavioral health needs and work with clinical social worker and interdisciplinary team to ensure all identified behavioral health needs are supported for the patient.

Supports prevention of unnecessary hospital admissions by completing daily medical appointment reminders to reduce missed medical appointments and being the liaison between the interdisciplinary team with medication refills, prior authorizations and other medical questions.

Works with interdisciplinary team on evaluation process in order to provide research documentation on the outcomes of the program.

As applicable, works with the population of patients transitioning from pediatric to adult programs to ensure all patient needs have been addressed. This may include establishing outreach, support groups, education, and support for career and medical needs, and also attending appointments, assisting with benefits, participating in annual retreats, meetings and grant projects related to transition.

Works with program-specific community-based organization(s) to provide support for patients/families and ensure partnership with the institution.

Identifies community resources that are maintained in a data base for supervisors’ reference.

Maintains understanding of financial assistance programs to include eligibility requirements and application process. Understands the VCUHS Indigent Care Program and the eligibility process to support patients in completion of application to assure access to care. Understands public support to include eligibility requirements, application process and services available once client is deemed eligible.

Maintains compliance with all program and VCUHS policies and procedures, as well as all JCAHO standards and state and federal guidelines and regulations, including completion of all required documentation

Performs other duties as assigned/or participates in special projects in order to support the mission of VCUHS and the department

Patient Population

The following must be included in all position descriptions that involve direct or indirect patient care. This is a Joint Commission requirement. Also, select the age of the patient population served:

Not applicable to this position.

Demonstrates the knowledge and skills necessary to provide equitable care appropriate to the age of the patients served on their assigned unit.

Demonstrates knowledge and related competencies of the principles of growth and development of the life span and possesses the ability to assess data reflective of the patient's status and interprets the appropriate information needed to identify each patient's requirements relative to their age, specific needs and to provide the equitable care needed as described in departmental policies and procedures.

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Neonates (0-4 weeks)

Adolescents (13-17 years)

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Infant (1-12 months)

Adults (18-64 years).

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Pediatrics (1-12 years)

Geriatrics (65 years and older)

Employment Qualifications

Education Qualifications - List the minimum education, training, and experience required to perform the essential functions of the position.

Required Education:

Bachelor’s or Master’s degree in Social Work or related field.

Preferred Education:

Licensing/ Certification - If registration, certification or licensure is required, include the name of the accrediting or licensing body.

Licensure/Certification Required:

Licensure/Certification Preferred:

Minimum Qualifications

Years and Type of Required Experience

Experience working with identified( Sickle Cell Adult) program population for a minimum of one year.

Other Knowledge, Skills and Abilities Required:

Knowledge of health care systems.

Demonstrated ability to relate to individuals and families of varied ethnicity, cultural backgrounds, ages and economic circumstances.

Ability to execute outreach plans, collect data and prepare reports.

Demonstrate skills in patient advocacy to assure access to care.

Excellent oral and written communication skills with the ability to listen, comprehend and effectively communicate.

Must have the ability to work independently, but also to work effectively within interdisciplinary teams.

Ability to work a flexible schedule.

Working knowledge and ability to use Microsoft Office programs.

Cultural Responsiveness

Demonstrates a commitment to diversity, equity, and inclusion through continuous development, modeling inclusive behaviors, and proactively managing bias.

Other Knowledge, Skills and Abilities Preferred:

Combination of education and experience in lieu of a degree.

Working Conditions - This section addresses the physical environment in which the employee will perform the work.

Periods of high stress and fluctuating workloads may occur.

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Long-distance or air travel as needed- not to exceed 10% travel.

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General office environment.

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May be exposed to high noise levels and bright lights.

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May be exposed to physical altercations and verbal abuse.

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May be exposed to limited hazardous substances or body fluids. *

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May be required to use physical restraints.

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May be exposed to human blood and other potentially infectious materials. *

May be exposed to adverse weather conditions; cold, hot, dust, wind, etc.

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May have periods of constant interruptions.

Required to car travel to off-site locations, occasionally in adverse weather conditions.

Prolonged periods of working alone.

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Other: Click or tap here to enter text.

* Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.

III.Physical Requirements

Physical Demands

Frequency

0%

1-33%

34-66%

67-100%

Lifting/ Carrying (0-50 lbs.)

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Lifting/ Carrying (50-100 lbs.)

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Lifting/ Carrying (100+ lbs.)

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Push/ Pull (0-50 lbs.)

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Push/ Pull (50-100 lbs.)

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Stoop, Kneel, Squat

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Crawling

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Climbing

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Balance

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Bending

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Work Position

Sitting

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Walking

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Standing

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IV.Additional Physical Requirements/ Hazards

Physical Requirements

Hazards

Select if a physical requirement for this job.

Select if a potential hazard for this job.

Manual dexterity (eye/hand coordination)

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Depth perception

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Perform shift work

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Use of Latex Gloves

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Maneuver weight of patients

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Exposure to toxic/caustic/chemicals/detergents

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Hear alarms/telephone/tape recorder

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Exposure to moving mechanical parts

Reach above shoulder

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Exposure to dust/fumes

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Repetitive arm/hand movements

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Exposure to potential electrical shock

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Finger Dexterity

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Exposure to x ray/electromagnetic energy

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Color Vision

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Exposure to high pitched noises

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Acuity – far

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Gaseous risk exposure

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Acuity – near

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Other: Click or tap here to enter text.

V. Mental/Sensory – Emotional

Mental / Sensory

Emotional

Select all that applies for this job.

Select all that applies for this job.

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Strong Recall

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Fast pace environment

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Reasoning

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Steady Pace

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Problem Solving

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Able to Handle Multiple Priorities

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Hearing

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Frequent and Intense Customer Interactions

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Speak Clearly

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Noisy Environment

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Write Legibly

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Able to Adapt to Frequent Change

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Reading

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Logical Thinking

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Other

EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.