Bilingual Nurse Navigator

This is a remote position - candidates must reside in the state of Texas. 

The RN Nurse Navigator for AOC’s Angel Link Health Home Services team will be directly supporting AOC’s Star and Star Kids clients. In collaboration with other members of the healthcare team, this role is responsible for organizing, coordinating, and providing care coordination and care management services to clients who are receiving private duty nursing services (PDN) from Angels of Care. The RN Nurse Navigator is responsible for assessing and coordinating client care across the continuum, utilizing accepted criteria and guidelines to manage Medicaid services and community resources. This position will function as a clinician, service coordinator, and educator to achieve optimal clinical and quality outcomes by effectively managing care and resources to improve the client experience for our families.

Duties and Responsibilities

• Work collaboratively with patients, families, physicians and AOC staff to ensure high quality care for PDN clients.
• Work with members of the client’s care team to better coordinate services and reduce burden on families.
• Coordinate with hospitals and Managed Care Organizations (MCO) during hospital admissions and hospital discharge planning to ensure all referrals for services are in place.
• Assist with scheduling follow-up physician appointments for clients as needed and provide routine check-ins to ensure client/family is attending physician appointments.
• Communicate client needs with AOC teams including Triage team, Intensive Case Management Team, and Clinical Care Managers (CCM’s) on all aspects of client’s care needs.
• Provide frequent and ongoing communication with the client and family to identify needs and escalate to the appropriate care teams.
• Researches, evaluates, and recommends resources to meet medical and non-medical needs of clients and families.
• Collaborates, refers, and communicates across all programs to ensure appropriate coordination of services.
• Act as the patient's advocate.
• Maintain the patient's comprehensive clinical record through detailed documentation in the EMR and Health Home Hub.
• Manage a caseload of clients who have been identified for health home services.
• Develop trust and build rapport with AOC clients/families.
• Develop relationships with the care coordination teams, physicians, and clinic staff.
• Maintain a courteous and helpful manner when working with patients, physicians, and associates.
• Assists client/families with self-management through education, visits and telephonic engagement; encourages and supports patient adherence to their care plans.
• Review patient non-compliance issues and conduct outreach to close them.

Qualifications

• Registered Nurse required
• Bilingual in Spanish and English required
• 2+ years Case Management experience in home health, managed care, or hospital case management (pediatric case management experience preferred)
• 2+ years of clinical experience in pediatric ambulatory care, inpatient setting, or home care
• Knowledge of case management, resource, and utilization management for Star Kids population