RN Care Navigator - Full-Time | Flexible | 36 - 40 hours weekly!Department:
Clinic ServicesCompensation:
$36-$58 per hour, based on relevant experienceSign-on Bonus:
$5,000Position Summary The RN Care Navigator provides patient outreach, education, care coordination, and ongoing support for high-risk patients served by Columbia County Health System (CCHS). The position initially focuses on patients managing complex medication regimens and patients who frequently miss primary care appointments. The Navigator helps patients overcome clinical and social barriers, coordinates services across providers and community resources, and supports patients in becoming more actively engaged in managing their health.
Essential Duties and Responsibilities - Identify and conduct outreach to eligible high-risk patients.
- Assess patients' clinical, care coordination, and social needs.
- Administer the Patient Activation Measure (PAM) and use results to guide individualized interventions.
- Develop individualized care plans with patients and the CCHS care team.
- Coordinate care among primary care providers, specialists, pharmacies, behavioral health, and other services.
- For patients with polypharmacy, coordinate structured medication reconciliation and medication review with pharmacists and providers.
- Connect patients to community resources, including referrals through Greater Health Now's Community Hub.
- Follow patients over time and document progress, barriers, interventions, and outcomes.
- Support patients who have repeatedly missed appointments in reconnecting with primary care.
- Maintain documentation necessary to support appropriate care-navigation billing.
- Participate in CQI activities, including Plan-Do-Study-Act (PDSA) cycles related to the Care Navigation program.
- Assist with monitoring program measures including PAM scores, missed appointments, medication reconciliation, ED utilization, readmissions, and relevant clinical outcomes.
- Collaborate with the Project Director, Data Analyst, providers, clinical staff, and community partners in evaluating and improving the program.
Minimum Qualifications - Current Washington State Registered Nurse license in good standing.
- Experience providing patient education, care coordination, case management, population health, or related nursing services.
- Ability to work independently and collaboratively across clinical disciplines.
- Strong patient communication, organization, and documentation skills.
- Ability to learn and use electronic health records, care-management systems, and program tracking tools.
Training After Hire - Patient Activation Measure administration and coaching.
- CCHS Care Navigation workflows.
- Quality improvement and PDSA methods.
- Community resource referral processes, including the Greater Health Now Community Hub.
- Documentation and time-capture requirements associated with billable care coordination/navigation services.
Grant-Specific Expectations This position is funded initially through CCHS's four-year HRSA Comprehensive Quality Improvement project. The Care Navigator will participate in Care Navigation program development and then lead patient-facing implementation. The project work plan calls for an initial 100-patient pilot beginning June 1, 2027, followed by evaluation and expansion.
Working Relationships Works closely with CCHS clinic providers, pharmacy, behavioral health, Population Health, Quality, Data Analytics, Revenue Cycle, and community partners. Greater Health Now supports the position through Community Hub referrals and training/support for use of the Patient Activation Measure.
