Job Information
CenterWell Divisional RN Care Navigator - Remote Houston in Houston, Texas
Become a part of our caring community and help us put health first
The RN Care Navigator assesses and evaluates member's needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward and facilitate interaction with resources appropriate for the care and wellbeing of members. The RN Care Navigator work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
The RN Care Navigator employs a variety of strategies, approaches, and techniques to manage a member's physical, environmental, and psycho-social health issues. Identifies and resolves barriers that hinder effective care. Ensures patient is progressing towards desired outcomes by continuously monitoring patient care through assessments and/or evaluations. May create member care plans. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
Major Duties and 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 wholistic view of patient needs related to Social Determinants of Health
Review mental, physical, social needs to trigger collaborative supports such as LCSWs, CHWs, MSWs, and pharmacists.
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 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 as needed via ZOOM
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
Use your skills to make an impact
Required Qualifications
Active Compact Licensed Registered Nurse
Role is remote, but candidates must live in Houston area
2 years of experience of case/care management
The National Council of State Boards of Nursing (NCSBN) developed the Nursing Licensure Compact (NLC), which is an agreement between states that allows nurses to have one license and the ability to practice in all the states that participate in the program. License must be current with no disciplinary action.
Openness to applying for temporary licensure if needed for other states.
Minimum of 4 years of experience working in human services and navigating community-based resources
Experience working with the adult population
Knowledge of community health and social service agencies and additional community resources
Ability to travel to member's residence within 30 to 40 miles
Exceptional communication and interpersonal skills with the ability to quickly build rapport
Ability to work with minimal supervision within the role and scope
Ability to use a variety of electronic information applications/software programs including electronic medical records
Intermediate to Advanced computer skills and experience with Microsoft Word, Outlook, and Excel
Excellent keyboard and web navigation skills
Ability to work a full-time (40 hours minimum) flexible work schedule
This role is a part of Humana's Driver Safety program and therefore requires and individual to have a valid state driver's license and proof of personal vehicle liability insurance with at least 100,000/300,000/100,00 limits.
Must have a separate room with a locked door that can be used as a home office to ensure continuous privacy while you work
Must have accessibility to high-speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana At Home systems if 5Mx1M
This role is considered patient facing and is part of Humana At Home's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
Valid driver's license, car insurance, and access to an automobile
Associates working in the State of Florida will need ACHA Level II Background clearance
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Preferred Qualifications
BSN
Familiarity with state Medicaid guidelines and application processes
Experience working with patients with behavioral health conditions and substance use disorders
Prior experience working with collaborative care teamsAbility to speak easily to providers, MDs, NPs
3-5 years of in-home assessment and care coordination experience
Experience with health promotion, coaching and wellness
Previous managed care experience
Bilingual - English, Spanish
Certification in Case Management
Motivational Interviewing Certification and/or knowledge
Additional Information
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 is remote. Interaction with clinics, meetings, educational groups can be conducted via ZOOM.
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
Workstyle: work from home; occasional clinic visits where location permits
Location: Must reside within the Houston TX area
Hours: Must be able to work a 40-hour work week, Monday through Friday 8:00 AM to 5:00 PM, over-time may be requested to meet business needs.
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.$69,800 - $96,200 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, 'Humana') offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), 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 unique care model focuses on personalized experiences, taking time to listen, learn and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists and more, 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 the nation's largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), 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 - for our teammates, patients, communities and company. 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 because he or she is a protected veteran. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
Centerwell, a wholly owned subsidiary of Humana, complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our full accessibility rights information and language options https://www.partnersinprimarycare.com/accessibility-resources