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Summary

Major Job Functions

The following is a summary of the major essential functions of this job.  The incumbent may perform other duties, both major and minor, that are not mentioned below.  In addition, specific functions may change from time to time:

• Provides proactive care that is intended to help improve the overall health and wellness of program participants

• Supplements employee wellness practices by implementing programs designed to reduce absenteeism and support health and safety in the workplace and broader community

• Provides an optimal mixture of healthcare and patient navigation at lower costs than traditional models

• Expands access and navigates non-urgent health care resources through mobile resources and/or community-based services

• Completion of in-home visits for patients with barriers to care that impede their ability to care for themselves or attend outpatient services

• Completion of comprehensive primary and secondary assessments to include chronic disease management, psychosocial evaluation and socioeconomic vulnerabilities

• Works in cooperation with other key stakeholders/key medical providers to offer coordinated and integrated care (physician offices, home health agencies, hospice, long term care facilities, public health department, social services, etc.)

• May perform moderate or waived point of care testing per CLIA guidelines

• Demonstrates standards of performance (respect, teamwork, communication, compassion) that support and encourage patient satisfaction and principles of service excellence

• Functions as physician and hospital extenders by utilizing advanced protocols/procedures approved by the Medical Director

• Other duties as assigned

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training: 

• High school diploma or equivalent required

• Current state licensure as a licensed practical nurse or registered nurse required

Work Experience: 

• 1 year case management, managed care program development and implementation, or geriatric experience preferred

• Previous experience in public health or integrated health care concepts required

Knowledge, Skills, and Abilities Required: 

• Knowledge of public healthcare, community navigation and transitional care

• Knowledge of Cumberland County geography, particularly locations of major streets, buildings, hospitals, doctors’ offices

• Ability to read road maps rapidly and accurately while under stress

• Knowledge of, and the ability to apply correctly, the policies and procedures of the ACO

• Ability to deal tactfully and firmly with patients, their support systems, the general public, other county, and/or city personnel

• Knowledgeable in chronic disease management, population health management, and age specific physiological, psychosocial, developmental and spiritual needs of target population group

Physical Requirements: 

• Hearing, speaking, and visual acuity are required

Required Licenses and Certifications

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity