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Posted: Wednesday, May 24, 2017 12:07 AM


The Coordinating Center is committed to improving health outcomes and reducing cost for individuals with complex health care needs. As part of this goal, the Health Plan Services Division works closely with community partners to provide care coordination services to individuals with complex and chronic health care needs. The goal of this program is to reduce hospital encounters, address barriers and increase appropriate utilization of community-based services, improve client engagement and self-management skills, and to maximize the individual’s health and wellness.

The R.N. Community Care Navigator is The Coordinating Center’s licensed health care professional who directs and provides care coordination services for individuals identified by our partners as high utilizers or those with rising risk to become high utilizers.

The R.N. Community Care Navigator is a key member of a multi-disciplinary team responsible for providing coaching and care coordination intervention for the target population. This is a community-based position that supports programs by performing complex care management assessments, including a risk cause analysis of current utilization of services to identify barriers to accessing appropriate care in the community. Collaborating with the client, their support team and their medical team to develop short and long-term goals based on their assessment and analysis and assisting in identifying barriers, the RN Community Care Navigator develops an appropriate plan of care to address interventions and self-management skills to meet these goals.

The RN Community Care Navigator works closely with other Health Plan Services Team members to identify appropriate community resources to meet the client’s health and safety needs and support the client’s ongoing self-management skills. They provide guidance to the client and their support team to stress the importance of preventative health activities to maximize their health and wellness and education on their disease processes to encourage early recognition of red flags, and developing appropriate responses to these red flags to prevent these episodes from becoming emergent. The Navigator identifies and links program participants to resources and services as necessary to address associated risks and close care gaps.

The multi-disciplinary team works out of The Coordinating Center’s Millersville location and delivers services telephonically and in-person at a member’s home, a healthcare facility and other locations in the greater Baltimore area as determined by the member and the team.

•Utilization of the care management process to guide service delivery.
•Supports clients by completing a Complex Care Management Assessment, including a risk analysis of current health care behaviors and social determinants. Utilizing this information to develop an appropriate plan of care to address barriers and self-management goals. The RN Community Care Navigator utilizes evidenced based protocols to promote self-management skills for meeting the client’s health and safety needs.
•Assist client in meeting value based preventative health measures by providing education on the importance of preventative health activities and addressing barriers to accessing these services.
•Assist in identifying participating providers to meet the client’s health and safety needs.
•Act as the liaison between the individual, the individual’s support network, treating physician(s), ancillary providers and payers utilizing a multi-disciplinary approach to address health and safety needs and measure optimal outcomes.
•Act as an advocate responding to and working to resolve individual’s concerns or barriers.
•Coordination of services and supports regarding individual’s health and safety needs.
•Assist with accessing appropriate community resources to meet health and safety needs not met by other resources. Including but not limited to behavioral health, housing, utilities, food, transportation, co-payments, equipment, in home support and attendant care.
•Assistance meeting client prioritized goals and desired outcomes.
•Support the Community Health Coaches in the field by fielding all medical related questions, responding to alerts and completing reassessments as indicated.
•Provide health education to the client, their support team and The Coordinating Center Team.
•Collaborate with hospital discharge teams, community physicians, insurer and other providers as indicated to support effective care by providing additional information from assessments and knowledge of client’s community supports and environment.
•Facilitation of cost effective alternatives to care.
•Serve as a resource to community service providers.
•Maintains communication with other members of the health care team.
•Maintains care management records.
•Document all activities into information system within 2 business days of activity
•Participation in all team related activities.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills, and/or abilities required:
•Bachelors of Science degree in nursing (minimum), Master’s degree is preferred.
•CCM certification is preferred and is required within two years of the date of employment at The Center.
•Minimum three years’ experience in one or more of the following areas:
oHospital based nursing in either adult medical, critical care or emergency room settings.
oDischarge Planning and Care Coordination.
oManaged Care Organization to include clinical, care management or utilization management setting.
oCommunity Health such as skilled nursing visits, physician’s office or specialty clinic or behavioral health setting.
oRehabilitation nursing in acute rehab setting.
•Demonstrated strong clinical knowledge of chronic illnesses such as COPD, CHF, Diabetes, Dementia and Wound Care.
•Demonstrates strong working knowledge of motivational interviewing for behavioral change.
•Demonstrates strong working knowledge of obtaining appropriate services and supplies through an insurer program.
•Demonstrates knowledge about value based care and gaps in care
•Understanding of performing a root cause analysis to identify barriers and evaluate effectiveness of care plans
•Experience in working with adults preferred.
•Experience in coordinating community based services.
•Experience in the elements of care transitions desired.
•Strong working knowledge of motivational interviewing for behavioral change
•Ability to demonstrate rapid change management to respond to the needs of our clients and our partners based on outcomes driven data.
•Cultural sensitivity and ability to communicate effectively with individuals with varied cognitive abilities to establish relationships.
•Ability to speak effectively with clients, partners and co-workers of the organization.
•Ability to read and interpret documents such as hospital discharge paperwork, assessment reports or medical records, and procedure manuals.
•Ability to document effectively in multiple Care Management Software Systems within 2 business days of activities.
•Additionally, R.N. Care Coordinators will demonstrate high clinical competence, an ability to work in a team situation with other professionals and have the ability to carry out responsibilities with minimal supervision.
•Proof of current state licensure and current malpractice insurance coverage is required
•Maintaining certifications as they apply to care coordination e.g. CCM, RNC.

• Location: Baltimore, Baltimore City, MD

• Post ID: 21035913 baltimore is an interactive computer service that enables access by multiple users and should not be treated as the publisher or speaker of any information provided by another information content provider. © 2017