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Category: Nursing Professionals
Facility: IHA Administration
Department: Care Team
Schedule: Full Time
Hours: 40 Hours
Job Details: Bachelor's Degree
Licensed Clincial Social Worker (LCSW)
Licensed Practical Nurse (LPN)
Registered Nurse (RN)
1 - 3 years of experience required

The Care Team Navigator is an integral member of the care team.  This individual provides initial care coordination for patients that are identified through risk stratification. Patients are then assigned to the appropriate care team member's panel. The Care Team Navigator is able to work with minimal supervision.




1.      Maintains in depth knowledge of all care team programs and enrollment criteria.

2.      Outreaches to patients telephonically and engages patients effectively into selected programs.

3.      Assesses patient needs by utilizing appropriate assessment skills and screening tools.

4.      Assigns patients to the panel of the appropriate care team member.

5.      Empowers patients to manage their health and provides targeted interventions to avoid hospitalization and emergency room visits.

6.      Refers selected patients to determined community resources and coordinates with these resources.

7.      Collaborates with patients and members of the health care team to ensure the delivery of quality, efficient, patient-centered, and cost effective healthcare services.

8.      Evaluates and manages day to day workflow and adjusts as needed to increase efficiencies.

9.      Attends required meetings and training, and participates in committees as requested.

10.   Assists with special projects and performs other duties as assigned and works within the scope of licensure.




1.      Creates a positive, professional, service-oriented work environment for staff, patients and family members by supporting the IHA CARES mission and core values statement.

2.      Must be able to work effectively as a member of the clinical team.

3.      Successfully completes IHA's "The Customer" training and adheres to IHA's standard of promptly providing a high level of service and respect to internal or external customers.

4.      Maintains knowledge of and complies with IHA standards, policies and procedures, including IHA's Employee Handbook.

5.      Maintains complete knowledge of office services and in the use of all relevant office equipment, computer, and manual systems.

6.      Maintains strict patient and employee confidentiality in compliance with IHA and HIPAA guidelines.

7.      Serves as a role model, by demonstrating exceptional ability and willingness to take on new and additional responsibilities.  Embraces new ideas and respect cultural differences.

8.      Uses resources efficiently.

9.      Responsible for ongoing professional development – maintains appropriate licensure/certification and continuing education credentials, participates in available learning opportunities. Responsible for completing additional HealthStream requirements for pre-operative education purposes (dictated by SJMHS).




Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position.  Care Management Metrics including productivity and ACP education and completion, and others defined by program.




EDUCATION:  RN (Bachelor of Science or Associates Degree in Nursing) or LPN or Licensed bachelors-level social worker

Completion of self-management support training preferred.

CREDENTIALS/LICENSURE:  Valid, unrestricted RN, LPN, BSW license in the State of Michigan

MINIMUM EXPERIENCE:   2-3 years of experience with primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical background.  




1.      Knowledge of patient care procedures and organizational policies related to position responsibilities.

2.      Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education

3.      Proficient/knowledgeable in medical terminology.

4.      Proficient in operating a standard desktop and Windows-based computer system, including but not limited to, electronic medical records and other care management and/or clinical IS systems, email, e-learning, intranet, Microsoft Word and Excel,  and computer navigation needed to complete the tasks of clinical care and performance reporting.  Ability to use other software as required while performing the essential functions of the job.

5.      Excellent communication skills in both written and verbal forms, including proper phone etiquette.  Ability to speak before groups of people.

6.      Ability to work autonomously and collaboratively in a team-oriented environment; courteous and friendly demeanor.

7.      Ability to work effectively with various levels of organizational members and diverse populations including IHA staff, providers, provider leadership, patients, family members, insurance carriers, vendors, external customers and community groups.

8.      Good organizational and time management skills to effectively juggle multiple priorities and time constraints.

9.      Ability to exercise sound judgment and problem-solving skills.  Demonstrated skills with influencing and negotiating individual and group decision-making.

10.   Ability to handle patient and organizational information in a confidential manner.

11.   Knowledge of the compliance and quality aspects of clinical care and patient privacy and best practices in medical office operations.

12.   Ability to travel to other office/practice sites and meeting and training locations.

13.   Successful completion of IHA competency-based program within introductory and training period.




1.      Physical activity that often requires keyboarding, phone work and charting.

2.      Physical activity that often requires extensive time working on a computer.

3.      Specific vision abilities required include close vision, depth perception, peripheral vision and the ability to adjust and focus. 

4.      Manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment.

5.      Must hear and speak well enough to conduct business over the telephone or face to face for long periods of time in English.




This job operates in a medical facility and requires regular walking to various locations around the hospital/clinic. Employees will be working where there is patient care equipment. Hazardous materials, including blood borne pathogens and bodily fluids are also present. Exposure to sharps, x-rays, patients' conditions and some unpleasant sights, smells and contagious diseases is possible.  This position requires significant interaction with people (many of whom are scared, hurt and/or ill) which can be stressful and result in competing priorities.


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