**Become a part of our caring community and help us put health first** Our Organization Humana’s Primary Care Organization is one of the largest and fastest growing value-based care, senior-focused primary care providers in the country, operating over 270 centers serving over 250,000 patients. As a payor-agnostic, wholly owned subsidiary of Humana, our centers put the unique needs of seniors at the center of everything we do. Our Clinics offer a team-based care model supporting patients’ physical, emotional, and social wellbeing. At CenterWell Senior Primary Care, we want to help those in the communities we serve, including our associates, lead their best lives. We support our associates in becoming happier, healthier, and more productive in their professional and personal lives. We promote lifelong well-being by giving our associates fresh perspective, new insights, and exciting opportunities to grow their careers. Our culture is focused on teamwork and providing a positive and welcoming environment for all. This is a unique opportunity to directly connect with patients on the barriers most affecting their ability to engage in the care they need, and subsequently work to find solutions that positively impact their quality of life. We are looking for individuals who are: • Dedicated to serving at risk populations most in need of additional supports • Creative problem solvers • Enthusiastic about working in a fast paced and developing market **The Role** Working within an interdisciplinary care team, the Care Navigator is responsible for proactively engaging patients identified as high-risk and implementing targeted interventions to address social needs and increase access to care. The Care Navigator will provide guidance and oversight of care coordination efforts to other members of the team, and handle clinical escalations as indicated. This role requires an understanding of how socio-economic stressors can impact ability to engage in healthcare and subsequent health outcomes. Experience will ideally include prior work with patients with behavioral health diagnoses, as well as in navigating local community-based resources and benefit applications. This role has a mobile presence, involving travel to patients’ homes, treatment facilities and community-based settings, and assigned clinics to facilitate and foster connections. **Major Duties and Responsibilities** + Conduct Transitions of Care Management for a subset of the patient population, including ER and hospital follow ups + Provide triage guidance and supportive consultation to other team members, handling escalated complex cases + Develop care plans leveraging 5Ms Geriatric best practice framework + Develop a wholistic view of patient needs related to Social Determinants of Health + Identify existing barriers to engagement with necessary resources and supports + Provide education around maintenance of chronic health conditions, as well as available options for behavioral care and social support + Serve as liaison between the patient and the direct care providers, assisting in navigating both internal and external systems + Initiate care planning and subsequent action steps for high-risk members, coordinating with interdisciplinary team + Supporting patients’ self-determination, motivate patients to meet the health goals they have identified + Refer patient to necessary services and supports + This field may include but is not limited to: assistance with transportation, food insecurity, navigation of and application for benefits including, Medicaid, HCBS, working to reduce costs associated with prescription medications, organizing schedules of follow up appointments, alleviating social isolation + Lead Interdisciplinary Team Meetings when indicated + Assess patient’s family system, and conduct family meetings with patient and family when needed + Participate in creation and facilitation of team training content + Conduct group psychoeducation and support groups within the Center + Perform all other duties and responsibilities as required + Participate in and lead interdisciplinary review of and coordination around complex patients + Maintain patient confidentiality in accordance with HIPAA + Document patient encounters in medical record system in a timely manner + Follow general policies related to fire safety, infection control and attendance + Flexibility to perform duties supporting other markets or regions as required **Required Qualifications** + Registered Nurse License + Minimum of 4 years of experience working in human services and navigating community-based resources **Preferred Qualifications** + LMSW Licensure if applicant holds an MSW + Bilingual in English/Spanish with the ability to speak, read and write in both languages without limitations and assistance + Familiarity with state Medicaid guidelines and application processes preferred + Experience working with patients with behavioral health conditions and substance use disorders preferred + Prior experience conducting home visits and knowledge of field safety practices preferred **Skills/Abilities/Competencies** + Advanced clinical acumen + Ability to multi-task in a fast-paced work environment + Flexibility to fluidly transition and adjust in an evolving role + Excellent organizational skills + Advanced oral and written communication skills + Strong interpersonal and relationship building skills + Compassion and desire to advocate for patient needs + Critical thinking and problem-solving capabilities **Working Conditions** This role has a mobile presence, involving travel to patients’ homes, treatment facilities and community-based settings, and assigned clinics to facilitate connections. **Workstyle:** Combination in clinic and field, local travel to meet with patients **Location:** Must reside in Richmond or Tidewater, VA metro areas Flexibility: Must work with other regions when required to support business operations. ​ **Hours:** Must be able to work a 40 hour work week, Monday through Friday 8:00 AM to 5:00 PM, over-time may be requested to meet business needs. **Use your skills to make an impact** **Required Qualifications** + Registered Nurse with 2 years of experience of in home case/care management + Experience working with the adult population + Knowledge of community health and social service agencies and additional community resources + Ability to travel to member's residence within 30 to 40 miles + Exceptional communication and interpersonal skills with the ability to quickly build rapport + Ability to work with minimal supervision within the role and scope + Ability to use a variety of electronic information applications/software programs including electronic medical records + Intermediate to Advanced computer skills and experience with Microsoft Word, Outlook, and Excel + Excellent keyboard and web navigation skills + Ability to work a full-time (40 hours minimum) flexible work schedule + This role is a part of Humana's Driver Safety program and therefore requires and individual to have a valid state driver's license and proof of personal vehicle liability insurance with at least 100,000/300,000/100,00 limits. + Must have a separate room with a locked door that can be used as a home office to ensure continuous privacy while you work + Must have accessibility to high speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana At Home systems if 5Mx1M + This role is considered patient facing and is part of Humana At Home's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB. + Valid driver's license, car insurance, and access to an automobile + Associates working in the State of Florida will need ACHA Level II Background clearance + Must be passionate about contributing to an organization focused on continuously improving consumer experiences **Preferred Qualifications** + BSN + 3-5 years of in home assessment and care coordination experience + Experience with health promotion, coaching and wellness + Previous managed care experience + Bilingual — English, Spanish + Certification in Case Management + Motivational Interviewing Certification and/or knowledge **Scheduled Weekly Hours** 40 **Pay Range** The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $69,800 - $96,200 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. **Description of Benefits** Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. **About Us** About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. Our unique care model focuses on personalized experiences, taking time to listen, learn and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patient’s well-being. About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation’s largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first – for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one. **Equal Opportunity Employer** It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Centerwell, a wholly owned subsidiary of Humana, complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our full accessibility rights information and language options https://www.partnersinprimarycare.com/accessibility-resources