Role Description The Care Navigator will be responsible for case management specific to kidney health management. The Care Navigator will complete activities for the continuum of care to facilitate and promote high quality, cost-effective outcomes for patients and focus on the whole patient and care delivery coordination. Managing a set caseload of mixed acuity members, the Care Navigator will: - Review and/or obtain member data and entry in HealthMap’s Care Management documentation system (Compass) - Complete member health and social determinants of health screenings - Perform medication reconciliation - Create and maintain member-centric care plans - Update identified problems, barriers, interventions, and goals - Assist with ongoing case management The Care Navigator will collaborate with internal and external (physicians, nurses, and other healthcare personnel) to assure positive patient outcomes and care coordination. Responsibilities - Handle in and outbound calls delivering world-class service to our members - Educate kidney health and related co-morbid conditions as well as optimizing renal replacement therapy by educating members on the types of dialysis and transplant options - Engage members into HealthMap’s Kidney Health Program - Follow up with members based on complexity and cadence by policy - Serve as patient advocate for responding and working to resolve concerns or barriers - Utilize community resources and programs in care planning - Serve as liaison between the patient, the patient’s support network, treating physician, and other ancillary providers as a member of an interdisciplinary care team to coordinate care, resolve nursing problems and assist patients in meeting individualized goals - Notify providers of identified patient needs based on policy - Comply with HIPAA privacy laws and all other federal, state, and local regulations - Comply with company-defined operational policies and procedures - Comply with company security policies - Accountable for individual metrics and key performance indicators identified by the organization - Navigate technical applications - Excel, OneNote, Outlook, and Word - Support after hours and various time zones based on business need - Drive patients and families in their own care and to support self-management Qualifications - Active, unrestricted RN license required - Bachelor's degree required - CCM preferred - Three (3) years of experience in case management preferred - Experience in a dialysis center or transplant center preferred - Experience with Medicare and Medicaid preferred Skills - Advocate and energize a culture of collaboration, positivity, and motivation - Strategic thinking and planning - Deliver effective communication – verbal and written - Succeed in a challenging environment with changing priorities Travel - No Travel