Patient Navigator, Accountable Care Organization

Patient Navigator, Accountable Care Organization

HMH HOSPITALS CORPORATION Hackensack, New Jersey

• Requisition #
• Shift: Day
• Status:
  Full Time with Benefits

A Patient Navigator, ACO works closely with primary care physicians and specialty services to maximize health status of very high risk ACO patients. The role requires high frequency of contact with patients and caregivers for education, health promotion, self‑care skills, and facilitation of quality measure compliance. The Navigator coordinates care plans and communications across transitions of care, applying advanced nursing knowledge to implement improvement processes in inpatient and outpatient settings.

• Perform a needs assessment of very high risk patients to improve health status and independence.
• Conduct extensive telephone assessment and triage of patients.
• Review office charts to identify gaps in care and coordinate services.
• Collaborate in a multi-disciplinary team to develop and implement comprehensive care plans for Medicare ACO patients.
• Utilize clinical tools such as protocols, physician orders, and care coordination models to maximize patient care.
• Identify patient and caregiver learning needs, assess ability to learn, and formulate individualized teaching programs.
• Work with physicians to ensure patient adherence to medical and preventive plans, including self‑management goals.
• Travel to patient locations as needed (hospital, skilled nursing facility, etc.).
• Assist patients and caregivers in obtaining specialist referrals and communicate with referring physicians.
• Facilitate communication of patient status during transitions of care.
• Participate in development and enhancement processes of the ACO to improve clinical experience and satisfaction.
• Utilize community services and programs to support patients at home.
• Monitor appropriate home care, hospice, and ancillary services.
• Maintain compliance with required quality measures.
• Collect and report data for quality improvement processes.
• Attend required training and collaboration sessions.
• Maintain flexibility in work schedule to accommodate patient and caregiver needs.
• Perform additional duties and projects as assigned.
• Adhere to HMH Organizational competencies and standards of behavior.

• Graduate of an accredited program in Nursing.
• Minimum of 5+ recent years in nursing.
• Highly developed interpersonal skills, including motivational interviewing.
• Proficiency at multitasking, prioritization, working with minimal supervision.
• Ability to work independently and in a team.
• Excellent analytical and deduction skills.
• Strong reasoning, problem‑solving, and initiative.
• Organized and capable of multitasking.
• Ability to work in stressful situations and accommodate patient and family needs.
• Proficient with PC and Microsoft Office.
• Excellent written and verbal communication skills.
• Proficient computer skills (e.g., Microsoft Office, Google Suite).

• Bachelor of Science in Nursing (BSN).
• Experience in various patient settings.

• NJ State Professional Registered Nurse License.

Minimum rate of $ Annually. The posted rate is an estimate of the minimum base pay and does not reflect the full value of the total rewards package.

The starting rate of pay is provided for informational purposes only and is not a guarantee of a specific offer.

• Labor Market Data:
  Compensation benchmarked against market data.
• Experience:
  
  Years of relevant work experience.
• Education and
  
  Certifications:
  
  Level of education, certifications, credentials.
• Skills:
  
  Demonstrated proficiency.
• Geographic
  
  Location:
  
  Cost of living and market rates for the specific location.
• Internal Equity:
  Compensation consistent with similar roles within the organization.
• Budget and Grant Funding:
  Departmental budgets and grant funding may impact pay.

Some jobs may also be eligible for performance‑based incentives, bonuses, or commissions. Certain positions may have shift differentials.

In addition to compensation for full‑time and part‑time positions, HMH offers a comprehensive benefits package.

All qualified applicants will receive consideration for employment without regard to age, race, color, creed, religion, sex, sexual orientation, gender identity or expression, pregnancy, breastfeeding, genetic information, refusal to submit to a genetic test or provide results, atypical hereditary cellular or blood trait, national origin, nationality, ancestry, disability, marital status, liability for military service, or status as a protected veteran.