The ACO LVN Navigator is a licensed clinical LVN who functions as a liaison between the ACO, the patient and the multidisciplinary healthcare team to assist in developing an optimal plan of care for transitioning Medicare patients, primarily those currently utilizing post-acute care services. The ACO Nurse Navigator assesses needs and coordinates resources within and outside the ACO (as approved by the ACO Director) to promote optimal health benefits and outcomes (both clinical and financial). The ACO LVN Navigator will provide onsite review at the local primary care practices and conduct patient home assessments as needed, as well as establish rapport with primary care providers, office staff, patients and their families to expedite timely transitions of care and appropriate utilization of post-acute care services.
This position requires a high frequency of contact with the very high risk ACO patient and their care givers for education of health promotion and self-care skills as well as facilitating compliance with the required quality measures for all ACO patients. An ACO LVN Navigator will also ensure the communication of a patient’s treatment plan and general status to all care givers during all transitions of care.