I. SUMMARY OF POSITION PURPOSE Piedmont Health Partners is a clinically integrated network owned by AnMed. The role of an Emergency Department Navigator is to establish and maintain collaborative relationships with physicians, other health care providers, patients and their families, to achieve desired patient outcomes throughout the continuum of care. It focuses on five primary areas: population management, patient self-management support, transitions in care, resource connection, and appropriate resource utilization. The goal is to work with providers and patients to help Piedmont Health Partners achieve the “Quadruple Aim” of lowering health care costs, improving patient satisfaction, elevating quality of care and enhancing the lives of healthcare providers in the network. The Emergency Department Navigator role is to reduce the use of emergency department care for non-emergent reasons. The Navigator will work with patients to support and/or achieve effective, efficient patient care transitions and access to care. The Navigator works with patients across a variety of settings and issues to assist with both clinical and nonclinical resources. The Emergency Department Navigator is based in the emergency department setting and responsible for facilitating all facets of Piedmont Health Partners population health strategies from emergency department and community settings as well as assigned service line initiatives. II. SPECIFIC DUTIES AND RESPONSIBILITIES + Works on streamlined, effective patient care transitions and navigates to appropriate care settings utilizing health system and community resources to effectively educate and empower patients in their self-management. + Conducts patient/family evaluations to determine care needs and plan of care. Adapts communication to specific patient populations, including but not limited to: respect for privacy, health literacy needs, cultural norms, etc. + Identifies social determinants of health (SDoH) while assessing patients in the Emergency Department to determine resources needed in order to promote client health outcomes and assist with coordination of community-based care referrals and navigation through system health care services as needed. + Identifies and coordinates multi-visit patients (MVP) efforts and other care coordination programs as assigned to reduce avoidable emergency department visits. Utilizes behavior change strategies to promote patient and family engagement in appropriate self-management of care. + Provides patient and family education as needed regarding chronic health conditions and system navigation. Emphasizes the importance of a medical home and proper utilization of emergency department and outpatient clinic services. + Participates in leadership with multidisciplinary teams to support organizational goals for managed populations, use of LEAN methodologies, and root cause analysis. + Collects data, analysis, and presents as assigned. + Researches, develops and implements special projects as identified to promote best practices and supports the organizational strategic plan and performance initiatives. + Facilitates warm and informed transitions of patients to external care settings and outpatient focused health partners. Optimizes patient experience during navigation efforts. + Models the mission, vision, and values, Standards of Excellence and goals of the Piedmont Health Partners and AnMed system. + Performs other duties and responsibilities as assigned and within time frame specified. IV. EDUCATION/QUALIFICATIONS + Master Social Worker (MSW), or related healthcare field with minimum 2 years' experience Required/Preferred Qualifications include: + Licensed Master in Social Work (LMSW) preferred. + Care Coordination, emergency department, ambulatory, or community health experience preferred. ACM certification preferred or willingness to achieve within 1 year. + Current South Carolina drivers license. + Highly organized and detailed oriented. Strong oral and written communication skills. + Understanding of motivational interviewing. + May be required to use personal transportation with mileage reimbursement. + Experience with Electronic Health Records (EHR), Microsoft 365, Microsoft Word, EPIC, and or other similar computer software. + Comfortable in a variety of settings with meeting patients and working with a team. + Willingness to learn new skills and function in a non-traditional healthcare role. + Able to accept changes and challenges in a positive manner that go along with the duties of this role. V. RESPONSIBILITY FOR MATERIALS AND EQUIPMENT Requires demonstrated computer skills and use of information systems as assigned. May be responsible for daily use of communication tools e.g. mobile phones, tablets, laptops, and other equipment as assigned or needed.