Care Gap & Chronic Care Nurse Navigator

Position Summary

Care Gap & Chronic Care Nurse Navigator is a position involving the provision of exceptional telephonic care coordination to patients with chronic conditions. This role will be a clinical expert, a patient advocate, and a key educator.

Reporting Relationships

This position reports to the Chief Nursing Officer.

Essential Job Duties and Functions

While living and demonstrating our Core Values, the Care Gap & Chronic Care Nurse Navigator will:

Conduct comprehensive monthly outreach to a dedicated panel of at least 40 Chronic Care Management (CCM) patients, assessing health status, evaluating treatment adherence, and providing health coaching.

Leverage EMR reports and registries to identify outstanding preventative health gaps (e. g., immunizations, diabetic eye/foot exams, cancer screenings) and facilitate necessary care.

Collaborate with patients, primary care providers, and the care team to establish, implement, and update personalized care plans for complex chronic conditions (e. g., diabetes, hypertension, COPD, CHF).

Perform timely post-discharge and post-ED outreach to reconcile medications, review discharge instructions, and schedule follow-up appointments to prevent avoidable readmissions.

Serve as the central point of contact for patients, coordinating appointments, diagnostic testing, specialist referrals, and pharmacy services.

Maintain accurate, timely, and complete documentation of all patient encounters, interventions, and care plan modifications within the Electronic Medical Record (EMR).

Ensure all care coordination and CCM time-tracking activities strictly adhere to Centers for Medicare & Medicaid Services (CMS) guidelines and quality standards.

Requirements

Meet The Wright Center for Community Health and its affiliated entity The Wright Center for Graduate Medical Education EOS© People Analyzer Tool

• Buy in and experience working in the EOS® model (strongly preferred)
• Mission-oriented; represents the enterprise in a professional manner while demonstrating organizational pride
• BS Degree in Nursing
• Registered Nurse in the state of Pennsylvania
• Previous experience in a health center setting a plus
• BLS Certification
• Experience with electronic health record, Medent a plus
• Ability to work as part of a care team
• Excellent communication skills
• Commitment to process improvement and quality