Job Description:

Overview In Central Minnesota, you'll find quality health care as near to you as CHI St. Gabriel's Health in Little Falls, part of CommonSpirit Health. We've been serving this area since 1892 and we have the equipment, experience, and expertise to offer you a full range of the latest health services. CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S. & from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community. CHI St. Gabriel's Health provides you with the same level of care you provide for others. We care about our employees' well-being and offer benefits that complement work/life balance. We offer the following benefits to support you and your family: * Health/Dental/Vision Insurance * Flexible spending accounts * Voluntary Protection: Group Accident, Critical Illness, and Identity Theft * Free Premium Membership to with preloaded credits for children and/or dependent adults * Employee Assistance Program (EAP) for you and your family * Paid Time Off (PTO) * Tuition Assistance for career growth and development * Matching 401(k) and 457(b) Retirement Programs * Wellness Program Responsibilities The person serving in the position of RN Navigator at Family Medical Center works collaboratively with physicians, staff and other health care professionals to provide a medical home and care coordination across the health care continuum for all patients within the physician office setting and is an integral member of the health care team who works to ensure safety, best practice and high quality standards of care are maintained. The RN Navigator is responsible for coordinating a wide range of self-management support and disease registry activities for the clinic's entire patient population. Essential Key Job Responsibilities Provide oversight of the disease registry database including: * a) Assuring database is kept up to date. * b) Identifying patients overdue for visits, labs, or referrals and arranging for follow-up services as appropriate. * c) Identifying patients not meeting clinical goals, such as BP control or glucose control, and arranging for follow-up services by protocol or as appropriate. * d) Creating patient, physician, and clinic level quality performance reports. Provide oversight or conducts pre-visit chart review of patients including: * a) Identification of all needed preventive health maintenance, immunizations, and chronic disease interventions. * b) When standing orders allow it the interventions may be ordered or completed before the patient sees a provider. * c) Fills out pre-visit forms or initiates office visits forms to communicate the review to the provider. Works with patients and families on Self-Management Support including: * a) Setting short and long-term goals for self-management of chronic disease. * b) Addressing medication adherence in patients not meeting outcome goals. * c) Works with patient to create a plan for Health Behavior Change utilizing the 5A's approach. Assessing and working on the patients readiness to change, the importance of change, and confidence in ability to change. Helping the patient to identify and overcome barriers * d) Makes a plan for follow-up between visits * e) Provides needed patient education regarding specific health care skills and general disease concepts. * f) Assist with shared medical appointments. * g) Communicating face-to-face in the office setting, by telephone, or by e-mail. Provides Coordination of Care across the care continuum including: * a) Assists as liaison with patients and their families to physicians, clinical staff, and other departments. * b) Acting as a liaison with hospitalized patients and the clinic by following up with patients by phone shortly after hospital discharge. * c) Acting as a liaison with specialty clinics. * d) Proactively acts as patient advocate, responding to and working to resolve patient concerns * e) Providing a link to community resources Involvement in QI activities: * a) Assesses clinic needs and then collaborates with Clinic Manager on strategies to achieve individual clinic level goals such as quality and efficiency. * b) Actively participates/coordinates committees as needed/requested, i.e. Performance Improvement Teams. * c) Communicates and coordinates with the healthcare team in the development of tools for optimal patient outcomes and report findings. * d) Meets on a regular basis with other population health managers, as coordinated by Clinic Administration, for information sharing and continuing education activities. Qualifications Requirements Registered Nurse in the State of Minnesota Graduate of accredited school of nursing approved by the State Board of Nursing and Associate's degree required, BSN preferred BLS certification Knowledge of and practical use of good business English, spelling, arithmetic practices and the ability to communicate effectively using written and verbal skills Preferred Minimum of three years of recent nursing work experience, preferably including experience in conducting nursing education Clinic/Physician office experience Background in Diabetes education