Practice Based Care Navigator

NTSP Holding Company, LLC Fort Worth, TX

The Practice Based Care Navigator works with the primary care practice team and is responsible for organizing, coordinating, and providing care coordination and care management services to patients within the practice who are most at risk for health deterioration, or poor outcomes. The highest risk patients are 1) transitioning to or from home and community-based health care facilities for acute care services (hospital or emergency department), rehabilitation services, skilled nursing services, or other community-based services; 2) being seen in the office with co-morbidities, unmanaged disease severity, poor self-care, polypharmacy, and high utilization rates.

The Practice Based Care Navigator as an integral part of the primary care team is responsible for ensuring that the primary care physician (PCP) and practice team maintains a central role in coordinating and managing the care of these vulnerable patients and that the patients receive optimal care including acute illness management, chronic disease management, and preventive care across multiple health settings and multiple physicians/providers.


• Leads and facilitates patient’s Integrated Decision Team

• Conducts comprehensive assessments of the client’s health and psychosocial needs, and develops a case management plan in collaboration with the client and client’s support system

• Ensures timely follow up appointment post discharge from hospital or skilled nursing facility to prevent readmission and related complications.

• Evaluation of and appropriate follow-up care for patients seen in the emergency department to prevent further disease exacerbation, untoward complications, or additional ER or hospital utilization.

• Management of patients identified by the PCP team as highest risk

• Demonstrates proficiency of clinical case review and appropriate levels of care across the care continuum for managing complex cases

• Demonstrates proficiency with caseload assignment and ability to manage complex cases effectively

• Identifies health disparities and removes barriers

• Demonstrates the ability to evaluate utilization/resource/clinical care management data to identify trends, develop action plans, and program modification for change

• Demonstrates a solid understanding of managed care trends, Medicare, and Medicaid regulations, reimbursement and the effect on utilization and outcomes of the different methods of reimbursement

• Educates the client, family or caregivers, and members of the health care delivery team about treatment options, community resources, insurance benefits, and/or psychosocial concerns so that timely decisions can be made

• Engages with patient to promote self- management

• Implements goals and objectives that support overall strategic plan of the organization

• Supports the mission statement, policies and procedures of the organization.

• Assists in eliminating boundaries to achieve integrated, efficient and quality service

• Achieves ongoing compliance with all regulatory agencies

• Serves as a resource to employees and customers as demonstrated by visibility and knowledge of issues.

• Demonstrates leadership and teamwork with others on the care management team

• Utilizes resources efficiently and effectively

• Maintains safe environment


• Bachelor’s degree in Nursing or Social Work


• Bachelor’s degree in related field


• 2-3 years’ experience in a healthcare setting.

• Related work experience will be considered in lieu of minimum required educational requirements.

• Working knowledge and ability to apply professional standards of practice in work environment.

• Working knowledge of computers and basic software applications used in job functions such as word processing, databases, spreadsheets, etc.


• 4 years’ experience in Complex Case Coordination/Management.

• Facilitating motivational interviews. Strong analytical and organizational skills.

• Working knowledge and ability to apply professional standards of practice in work environment.


• Licensed RN, LVN or Social Worker.

• In good standing with the respective state board.


• Strong clinical assessment skills, critical thinking, and effective organizational and management skills, strong problem skills.

• Effective IDT facilitating

The above job description is not intended to be an exhaustive list of all responsibilities, duties, and skills required of the job. Management retains the right to add or to change the duties of the positions at any time with or without notice.

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