Patient Care Navigator MSW, Transitions of Care

Hourly Pay Range:

$32.60 - $48.90 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.

Position Highlights:

• Position: Patient Care Navigator-MSW
• Location: Warrenville, IL
• Full Time: 40 hours
• Hours: Monday-Friday, 8:30a-5:00p, 2 days onsite required and 3 days remote optional. Weekend and holiday required per rotation. Remote optional for weekend and holiday coverage.

A Brief Overview:
The SW Care Navigator is responsible for the case management and care coordination of his/her population of patients from the time of diagnosis (could be pre-admission or in the ED) to 90 days post-discharge. This position will collaborate with the RN Care Navigator. This position involves helping patients understand their diagnosis, treatment options, and ensure that they are connected with the optimal resources across the continuum of care. The SW Care Navigator will help to identify and address complex family dynamics and other social determinants of health. This role will coordinate discharge planning by facilitating smooth transitions of care while ensuring quality cost-effective patient outcomes. Serves as a liaison between their patient population and all other providers. Will be responsible for key metrics of success, which include improving the overall cost of care, length of stay optimization, reduction in excess days, reduction in SNF utilization and improvement in SNF care transitions, reduction in 30-day readmission rate and ED utilization.

What you will do:

• Connects with patient at the time of diagnosis (either ED or pre-admission) and follows the patient across the hospital stay and 90 days post discharge. Guides patient and family through the health system from diagnosis, testing, treatment and follow-up care to assist patients with navigating the continuum of care. Eliminates barriers to patient's access to health care services and facilitates continuity of care/care coordination.
• Partners with the healthcare team to ensure clinical decision-making, implementation of recommendations, and discharge planning are timely and appropriate.
• Oversees and facilitates effective and impactful interdisciplinary rounds that are structured and standardized.
• Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas.
• Performs daily coordination between multiple departments, multi-disciplinary team, medical clinics, and community outreach to gain knowledge of patient, assure patient safety, smooth transitions of care, and manage utilization and total cost of care.
• Routinely assesses and monitors the patient’s status, needs, and progress by proactively reaching out to the patient/caregiver and ensuring that they are connected to the most appropriate and impactful resources.
• Acts as advisor/educator by providing emotional support including goals of care and counseling. Provides and/or arranges clinical education including medication management, community resources, financial resources, and expert guidance to patients and families to promote their ability to understand and meaningfully participate in the healthcare process and personal decision-making.
• Responsible for outreach efforts to establish and maintain positive working relationships with patients, family including multidisciplinary team i.e. physicians, office staff, diagnostic staff, nurses, social services staff, home services etc.
• Facilitates appointments for appropriate consultations and support services within established protocols
• May need to travel to visit the patient at home.nnects with providers across the care continuum proactively and in a timely way.
• Available to his/her assigned patient population 24/7 and participates as part of a call coverage structure.
• Participates in handoff processes within the team to ensure that patients are connected to the care navigator program across their care episode.
• Participates in the collection and analysis of data to identify under/over utilization; improve resource consumption; promote potential reduction in cost; and enhance quality of care consistent with organization strategic goals and objectives.
• Conducting precertification, concurrent, and retrospective utilization management through the application of nationally recognized criteria.
• Additional Essential Functions SW Care Navigator
• Follows patients throughout the care continuum including emergency room, inpatient admissions, home care, outpatient services and primary and specialized appointments.
• Ensures that patients have and keep post-discharge follow-up appointments and that their medications are accurate and appropriately reconciled at each point of care.
• Helps patients understand their insurance coverage as well as the post-acute level of care, necessary durable medical equipment required for recovery.
• Develops concise patient itinerary for use by the patient and the care team, and documents all communication with the patient so it is visible across the care team
• For patients who are discharged to settings other than home, works with the providers and teams at those facilities to ensure patients are meeting goals of care and transitioned efficiently and effectively back to the home setting.
• Develops, plans and presents patient education programs and tools and enrolls patients in these programs so they are able to benefit maximally from all of the program elements.
• Provides emotional support and counseling to the patient and caregivers
• Helps patients understand their insurance coverage as well as the post-acute level of care, necessary durable medical equipment required for recovery
• Coordinates and collaborates with inpatient continuum Care Manager while the patient is hospitalized, accepting hand off at the time of discharge.
• Completes and documents assessment in accordance with NorthShore and health plan requirements.
• Develops, implements, updates individualized care plan for patient until program completion.
• Documents in health plan portals as required.
• 1. Subject Matter Expert
• a. Model behaviors and organizational standard to promote quality, patient safety, and enhanced patient care coordination.
• b. Knowledge of Medicare, Medicaid, and Third party reimbursement (i.e. HMO and Health Plan Benefits).
• 2. Teamwork
• a. Actively participates in performance improvement and other approaches. Collaborate with the team members to develop effective work processes that may lead to improvement of work.
• b. Has a good understanding of the goals and expectations so to develop work functions across the team is aligned and synergistic.
• c. Leads regular staff huddles, interdisciplinary rounds, and other meetings to update team and give progress reports.
• 3. Risk Management – Uses insights from risk management and patient advocacy to understand opportunities to improve day to day operations of care coordination.
• 4. Other Duties – As this job evolves, this role will complete others duties assigned.

What you will need:

• Masters Degree Required
• 2 Years 2+ years of related health care experience. Discharge planning, case management, home services, ambulatory services working with high risk patients beneficial. Experience with behavioral health also beneficial.
• Able to communicate and work collaboratively with a range of stakeholders and team members
• Knowledge of community resources
• Experience with Microsoft Office Suite
• Strong interpersonal and oral communication skills
• Strong computer and data entry skills
• Experience with Electronic Medical Record (EMR) platform preferred
• Proven leadership skills
• Ability to work independently, setting priorities to coordinate care plan efficiently
• LCSW strongly preferred Preferred Or
• Master’s degree in social work required. Required Or
• Clinical certification, such as case management certification, is beneficial. Required Or
• Basic Life Support for Healthcare providers (AHA) or CPR/AED for the Professional Rescuer (American Red Cross) Required

Benefits (for full and part time positions):

• Premium pay for eligible employees
• Career Pathways to Promote Professional Growth and Development
• Various Medical, Dental, and Vision options, including Domestic Partner Coverage
• Tuition Reimbursement
• Free Parking at designated locations
• Wellness Program Savings Plan
• Health Savings Account Options
• Retirement Options with Company Match
• Paid Time Off and Holiday Pay
• Community Involvement Opportunities

Endeavor Health is a fully integrated healthcare delivery system committed to providing access to quality, vibrant, community-connected care, serving an area of more than 4.2 million residents across six northeast Illinois counties. Our more than 25,000 team members and more than 6,000 physicians aim to deliver transformative patient experiences and expert care close to home across more than 300 ambulatory locations and eight acute care hospitals – Edward (Naperville), Elmhurst, Evanston, Glenbrook (Glenview), Highland Park, Northwest Community (Arlington Heights) Skokie and Swedish (Chicago) – all recognized as Magnet hospitals for nursing excellence. For more information, visit www.endeavorhealth.org.  

When you work for Endeavor Health, you will be part of an organization that encourages its employees to achieve career goals and maximize their professional potential.

Please explore our website (www.endeavorhealth.org) to better understand how Endeavor Health delivers on its mission to “help everyone in our communities be their best”. 

Endeavor Health is committed to working with and providing reasonable accommodation to individuals with disabilities. Please refer to the main career page for more information.

Diversity, equity and inclusion is at the core of who we are; being there for our patients and each other with compassion, respect and empathy. We believe that our strength resides in our differences and in connecting our best to provide community-connected healthcare for all.

EOE: Race/Color/Sex/Sexual Orientation/ Gender Identity/Religion/National Origin/Disability/Vets, VEVRRA Federal Contractor.