Clinical Quality Outreach Navigator

OHI is switching to four, ten-hour shifts in January, 2025. Candidate must be able to commit to this schedule in 2025.
Position Summary Reporting to the Director of Nursing, the Clinical Quality Outreach Navigator will coordinate quality improvement efforts for any measures/indicators identified by Ocean Health Initiatives (OHI). The individual will perform care including telephoning patients, documenting in EMR, and completing aspects of chronic care management. The Clinical Quality Outreach Navigator plans, coordinates, and evaluates services utilizing the direct nursing process, comprehensive nursing care and individual case management. The Clinical Quality Outreach Navigator will outreach to participants of the Making Care Primary program to offer this support service program to engage patients in care management services.
Clinical Quality Outreach Navigator Responsibilities Proactive outreach to patients who may benefit from chronic care management services.Follow up outreach for support lab/image/referral tracking, gaps in care and other quality measure improvement efforts.Engaging patients in creating, implementing, and monitoring care plans that promote successful outcomes.Effective and compassionate communication with patients and their natural supports to use Social Determinants of Health survey results to guide individualized plans.Works with patients to complete intake documents to identify needs by reviewing knowledge skills and resource gaps that can facilitate goal achievement.Frequent telephonic interactions with patients and their significant others to close gaps in care.Coordination with other members of the care team, Providers on the care team and consultants to close gaps in care and update EMR.Completes and submits all Care Delivery Intervention Reports to DON including those for MCP according to Section 5.2a-f of CMS agreement.Acts as a liaison between patients, primary care practices and population health and Quality teams in the provision of care.Facilitates partnerships with community partners and resources to assist patients in closing gaps in care.Uses evidence-based coaching techniques to help patients design realistic health goals, implement positive lifestyle changes and achieve desired plan in support of a healthier lifestyle and disease state.Works as part of the interdisciplinary team to meet the goals of the Practice, the provider and the patient. Will support the population health and transformation initiatives as assigned.As a member of the patient care team, documents in the EMR, the patient interactions and care planning activities as directed by the Provider and care team.Identifies and appropriately escalates patient related issues to Provider when required.Utilizes data to better understand and tailor interventions to the patient populations.Attends/presents status updates at meetings.Supports the Transformation efforts as needed.Regional travel required, use of personal vehicle with mileage reimbursement (consistent with company policy) - driver's license required.Other duties and/or projects as assigned.Additional Clinical Responsibilities May Include Provides nursing care including administration of medications and injections to patients as directed by Providers, immunizations, referrals to other providers and community health resources, preauthorization's as required for any testing and health instructions to patients following examinations.Completing patient intake by documenting past and current medical diagnoses, concerns, medications, allergies, smoking history, and other pertinent social history.To obtain and document patient's vital signs, including blood pressure, respiration rate, pulse, pulse oximetry, height and weight. All information is documented utilizing an EMR.To assist provider in patient education on smoking cessation, healthy diet and healthy lifestyle choices.Instruct and assist patients to remove shoes to obtain accurate weight and inspect feet of diabetic patients.Assist providers with education and disease management for chronically ill patients (ex. Hx of diabetes, asthma).As a part of the uniform requirement, CMA must wear wrist-watch with second hand to obtain accurate vital signs provide safe and quality patient care.Reviews level of pain with patient and documents all vital signs in patient's chart in the EMR.Performs dipstick Urinalysis, pregnancy tests (OB), vision and hearing tests, and head circumference measurement (Pediatrics). Documents all findings in patient's chart in EMR. Collaborates with provider for further follow up on any tests as needed.Monitors patient flow and assists in preparation of examination rooms, chairs and preparation of patients for exam. Effectively work with a care team to deliver safe and quality patient care.Administers vaccines according to policy using two identifiers, provides proper education and information sheets to patients/guardians, and accurately documents information in EMR.Enters appropriate patient data and all the vaccine information in NJIIS Registry right after the vaccine is administered.Enter refrigerator/freezer temperatures appropriately and in a timely manner in NJIIS as required by VFC (Vaccines for Children).Maintain an accurate, and daily temperature log for refrigerator/freezer thermometer to assure vaccine and medication safety. Update the log monthly, file the log for previous month and send a copy to DON by 5th of each month.Inspect and check medications/vaccine expiration dates on a continuous basis, and maintain the expiration medication log.Clean refrigerator monthly and maintain an up-to-date refrigerator cleaning log.Utilize time management skills, multi-task in a fast-paced environment. Maintain nursing competency and patient confidentiality.OB and PEDS CMA will inquire about patient's dental needs and assist the patient to schedule a dental appointment.Notify SW for the need of an assessment on any patients with a history of depression or suicidal thoughts, or any high-risk patients.Maintains adequate stock of routine medical supplies; orders supplies through established purchasing procedures monthly and as needed, and maintains all necessary logs updated. Sends copies of all logs to DON monthly.Maintains updated file of referrals and provides referral information to Providers.Provides direct and/or indirect patient care oriented toward improving or maintaining health and preventing illness.Observes patient, records significant conditions and reactions, and notifies Provider of patient's condition and reaction to drugs, treatments, and significant incidents.Initiates a patient education plan according to the individualized needs of the patient, as prescribed by Provider and OHI policy including patient and family instruction.Reconciles labs within normal limits, reports critical labs and abnormal results to Provider following OHI policy.Complete various forms as requested by a patient and report to provider for final review and management.Reports required information to the Health Department for further screenings and follow-up.Ensures chart preparation is completed and enters appropriate orders based on outstanding Quality Measures for Provider to review daily.Maintains and updates patient charts, records, and information found in EMR.Inspects Environment of Care for any safety concerns and infection control issues and intervenes as appropriate. Completes monthly EOC report and reports findings to PSM according to protocol.Reports all necessary information and/or unusual occurrences in accordance with established policies and procedures and notifies DON/Practice Site Director/Coordinator of unusual occurrences as they develop.Completes incident reports immediately as per policy in all required situations.Reports action of others which have negative impact on patient care.Promotes and delivers optimum satisfaction to all patients.Responsible for knowledge of compliance, where applicable, with regulatory or credentialing agencies.Maintains own professional competence through participating in continuing education and other appropriate learning experiences.Ensure compliance with risk management and corporate compliance as outlined in OHI's corporate compliance manual.Provides effective coaching and training to staff and ensures staff has the necessary tools and information to perform their roles.Committed to continuous quality improvement acts on own areas for self-improvement and best practices.Works collaboratively with human resources to ensure training is completed and timely follow up and support to employees is being provided.Tracks employee training progress on the Monday.com and uses Monday for all compliance tracking.Develops and collaborates on the creation and updating training materials with other members of the Senior Management and management team as needed.Conducts trainings for the organization as needed in group or individual settings.Ability to be flexible, seeks new approaches and fosters a healthy, positive collaborative environment.Has effective communication and interpersonal skills and listens appropriately.Is self-motivated and demonstrates creativity, initiatives ideas and implements change/automation to improve organizational efficiency.Attend all mandatory in-services meetings and completes required in-services timely.Is highly accountable for one's own productivity. In order to maintain transparency, all projects must be represented clearly on a project board in Monday.com. Responsible for ensuring the board is always updated and accurate and that information is accessible to those that need it.Adheres to Corporate Compliance policies.Maintains a passing monthly scorecard threshold at 80%.Other duties as assigned.Education/Experience/Licensure Graduate of accredited Certified Medical Assistant or Licensed Practical Nursing program is required.One to three years CMA or LPN experience in medical or community health care settings is required.Active State of New Jersey CMA certification or LPN license is required.Certified Basic Life Support through American Heart Association is required.Three to five years of experience teaching, training or educating in a related health care field is preferred.Proficiency in Microsoft Office 365 is required.Bilingual English/Spanish is preferred.Flexibility to meet the hours of the practice including evenings and weekends is required.Flexibility to cover shifts at other current and future OHI sites is required.Must have your own reliable transportation throughout Ocean and Monmouth Counties as required by OHI.Pre-Employment Requirements: PhysicalCriminal Background ChecksDrug ScreeningTuberculosis ScreeningOcean Health Initiatives is firmly committed to creating a diverse workplace and is proud to provide equal employment opportunities to all applicants. Therefore, Ocean Health does not discriminate on the basis of creed, color, national origin, sex, gender identity, sexual orientation, age, religion, marital or parental status, alienage, disability, political affiliation or belief, military or military discharge status. In accordance with New Jersey Executive order (COVID-19 No.283) in conjunction with the Federal CDC guidelines, COVID vaccinations are a requirement for Ocean Health Initiatives as well as many other Healthcare Organizations. Proof of full vaccination and the booster shot is required prior to the beginning date of employment. If you have a medical or religious contraindication, please inform Human Resources when the offer is extended.

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