ED Navigator

Port Jervis, New York, The ED Care Manager coordinates multidisciplinary care to provide health services to individuals through effective partnerships with patients, caregivers, families, community resources and physicians. Facilitates navigation within a patient centered model and across settings to achieve coordinated care that is efficiently provided in an optimal manner. RESPONSIBILITIES: The ability to multitask and work in a fast paced emergency department is essential. Coordinates care to obtain desired health outcomes, improve self-care abilities, decrease cost of care, and provide extraordinary patient care in the process. Utilizes evidence-based medicine, data analytics and innovation in implementing care management principles to meet patients and their families’ needs. Understands and applies principles of population health management to identify patients with high risk conditions and/or rising risk indicators and facilitates a plan of care that addresses such needs. Ability to communicate and relate with individuals of all backgrounds and levels of communication. Works with a multidisciplinary team and patients to develop, implement and monitor a comprehensive plan of care to prevent, mitigate and/or manage varied healthcare conditions. Identifies high risk patients and create a plan of care to address their vulnerable conditions. Navigates identified patients to primary and preventative care by assisting patients in obtaining a PCP and/or enrollment in chronic disease management care.

Coordinates follow up appointments with PCP and community providers. Utilizes the EMR, PSYKES and Healthily for care transitions and discharge planning purposes. Knowledgeable in the DSRIP/ACO activities associated with care management, including identification of patients eligible for Health Home services (and/or active Health Home enrollment), care management, behavioral health, creating documentation and adhering to workflows. Serves as a member of both the Acute Case management and Ambulatory care management teams and performs appropriate department functions by attending meetings and adhering to documentation requirements. Assesses patient/family abilities to self-engage and develops individualized patient/family education plan focused on development of self-management skills based on System’s standard care protocols. Recommends alternative levels or modalities of care and ensures compliance with federal, state, and local requirements. Advocates the completion of living wills and advance care planning and where appropriate begin palliative care consults. Communicates clear, complete and accurate documentation in a health record to ensure that all those involved in a client’s care have access to information upon which to plan and evaluate their interventions. Updates plan of care timely to ensure all members of the care team have timely information regarding the patients’ status. Performs other tasks as assigned.

QUALIFICATIONS/REQUIREMENTS: Registered Nurse, Care management experience in the emergency department and/or working with vulnerable populations preferred.
* High level verbal and communication skills and organizational skills a must. Competency in electronic medical records required, Epic preferred. Case/Care management certified or knowledge of national care management standards and community resources a plus. Office Equipment Used Phone, printer, computer literacy; competent with MS Office EDUCATION: Bachelor’s degree required, or Licensed Clinical Social Worker or equivalent with 5+ years acute care/ambulatory care experience About Us: Bon Secours Charity Medical Group Bon Secours Charity Medical Group, part of Bon Secours Charity Health Systems (BSCHS), a regional network of more than 120 primary care physicians and specialists from a broad array of medical specialties. BSCHS, a member of WMCHealth Network, includes Good Samaritan Hospital in Suffern, NY, Bon Secours Community Hospital in Port Jervis, NY and St. Anthony Community Hospital in Warwick, NY.

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