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Care Navigator at SCL Health in Grand Junction, Colorado

Posted in Other 30+ days ago.

Type: Full Time

Job Description:


You bring your body, mind, heart and spirit to your work as a Care Navigator.

Youre generous with your thoughts, your partnerships, and your passion for patient care coordination.

Youre equally comfortable with patient assessment/education, risk stratification, discharge planning, and post-acute care plan development.

Youre great at what you do, but you want to be part of something even greater. Because you believe that while individuals can be strong, the right team is invincible.


St. Marys Medical Center is part of SCL Health, a faith-based, nonprofit healthcare organization that focuses on person-centered care. Our 346-bed regional medical center is in Grand Junction, one of the most beautiful places on earth. Our mission is to bring health and hope to the poor, the vulnerable, our communities and each other.

Benefits are one of the ways we encourage health for you and your family. Our generous package includes medical, dental and vision coverage. But health is more than a well-working body: it encompasses body, mind and social well-being. To that end, weve launched a Healthy Living program to address your holistic health. Healthy Living includes financial incentives, digital tools, tobacco cessation, classes, counseling and paid time off. We also offer financial wellness tools and retirement planning.


Together well align mission and careers, values and workplace. Well encourage joy and take pride in our integrity.

Well laugh at each others jokes (even the bad ones). Well hello and high five. Well celebrate milestones and acknowledge the value of spirituality in healing.

Were proud of what we know, which includes how much there is to learn.


As a Care Navigator you need to know how to:

* Lead the collaboration of the patient care teams in managing Episode Payment Model (EPM) patients from pre-hospitalization throughout their inpatient stay, ensuring the most appropriate discharge disposition, providing care coordination and health coaching while addressing the social determinates of health and other barriers throughout the 90 day episode of care.

* Collaborate with multiple stakeholders to obtain management, staff, and physician involvement and accountability in achieving goals to improve patient outcomes and experience, while reducing healthcare costs.

* Contact all assigned EPM patients, for the purposes of education, risk stratification, identification of barriers to success and post-acute care planning. Provide patient, caregiver and family education to ensure understanding of disease process and management.

* Complete follow-up task lists, working with the patient, family and care teams to remove potential barriers for a discharge to home and creates a post- acute care plan, including backup options. Document the post-acute plan in the designated EPM documentation application and utilize all applicable EPM tools and resources throughout the episode period.

* Develop transitional care plan for at least 90 days post hospitalization in collaboration with patient/family and care team which may include but not limited to, physician/surgeon/specialist, PA/NP, hospitalist, case managers and care coordinators.

* Participate in regular care site and system team meetings, huddles, staff meetings, and quality improvement projects to improve patient care. Ensure that hospital team is aware of EPM program requirements and assist leadership with performance improvement projects.

* Collect and submit all payer required forms/documents including those required for fee for service Medicare patients under the Medicare demonstration projects in addition to other voluntary forms, surveys or other documentation deemed necessary for quality or educational purposes.


We hire people, not resumes. But we also expect excellence, which is why we require:


Bachelors degree, required

Social Worker (BSW or MSW/LCSW) or, current RN (registered nurse), required

Minimum of four (4) years of case management/care coordination experience, in either an acute care setting, payer UM department, ambulatory care setting, or post-acute care setting, highly preferred

Demonstrated experience in data collection, tracking, and reporting, required

Previous Epic experience, preferred

Masters level degree, preferred

Current ACMA or CCMC certification, preferred

Previous experience in an episode payment model program, preferred


Now that you know more about being a Care Navigator we hope youll join us. At SCL Health youll reaffirm every day how much you love this work, and why you were called to it in the first place.

Our facilities do not discriminate against any person on the basis of race, color, national origin, disability, or age in admission or access to, or treatment or employment in, its programs, services or activities, or on the basis of sex (gender) in health programs and activities