Become a part of our caring community and help us put health firstThe RoleWorking 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 upsProvide triage guidance and supportive consultation to other team members, handling escalated complex casesDevelop care plans leveraging 5Ms Geriatric best practice frameworkDevelop a wholistic view of patient needs related to Social Determinants of HealthIdentify existing barriers to engagement with necessary resources and supportsProvide education around maintenance of chronic health conditions, as well as available options for behavioral care and social supportServe as liaison between the patient and the direct care providers, assisting in navigating both internal and external systemsInitiate care planning and subsequent action steps for high-risk members, coordinating with interdisciplinary teamSupporting patients’ self-determination, motivate patients to meet the health goals they have identifiedRefer patient to necessary services and supportsThis 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 isolationLead Interdisciplinary Team Meetings when indicatedAssess patient’s family system, and conduct family meetings with patient and family when neededParticipate in creation and facilitation of team training contentConduct group psychoeducation and support groups within the CenterPerform all other duties and responsibilities as requiredParticipate in and lead interdisciplinary review of and coordination around complex patientsMaintain patient confidentiality in accordance with HIPAADocument patient encounters in medical record system in a timely mannerFollow general policies related to fire safety, infection control and attendanceUse your skills to make an impact Required Qualifications Registered Nurse (RN license)Minimum of 4 years of experience working in human services and navigating community-based resourcesPreferred QualificationsFamiliarity with state Medicaid guidelines and application processes preferredExperience working with patients with behavioral health conditions and substance use disorders preferredPrior experience conducting home visits and knowledge of field safety practices preferredSkills/Abilities/Competencies RequiredAdvanced clinical acumenAbility to multi-task in a fast-paced work environmentFlexibility to fluidly transition and adjust in an evolving roleExcellent organizational skillsAdvanced oral and written communication skillsStrong interpersonal and relationship building skillsCompassion and desire to advocate for patient needsCritical thinking and problem-solving capabilitiesWorking 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 patientsLocation: Must reside in Richmond, VA metroHours: 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.Scheduled Weekly Hours40Pay RangeThe 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 yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.Description of BenefitsHumana, 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 UsAbout 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 EmployerIt 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.