Value-Based LPN Care Navigator

The Value-Based LPN Care Navigator supports the delivery of high-value, team-based care by providing practical nursing support within ambulatory settings. This role helps coordinate and prioritize patient care activities under the supervision of a registered nurse or provider, ensuring continuity and comprehensiveness across the care continuum. The incumbent utilizes their skills and knowledge base to provide care coordination with a designated patient panel to address preventive care needs, chronic disease management, and care gap closures, ultimately improving patient outcomes and performance in value-based payment models.

• Supports management of an assigned patient panel to improve performance on value-based contractual goals under the direction of the High Value team and within scope of licensure.
• Conducts focused assessments and documents findings and interventions in the Electronic Medical Record (EMR) system.
• Consistently meets established productivity and performance targets.
• Assists in identifying and addressing patient care needs, including support for preventive care, chronic condition management, and follow-up after emergency or inpatient care.
• Communicates observed changes in patient condition or needs to supervising RN or provider to support updates to the care plan.
• Participates in team-based population health activities, including outreach and patient engagement for screenings and chronic care services.
• Completes documentation to support Chronic Care Management (CCM) and care coordination activities in compliance with program requirements.
• Collaborates with the other members of the interdisciplinary care team to address the needs of complex patients and ensure appropriate interventions have been completed to meet goals, functioning as an embedded team member within the clinic.
• Monitors and follows up on assigned care plan tasks, escalating clinical concerns appropriately.
• Actively participates in staff meetings, goal setting, quality improvement initiatives, and efforts to enhance patient satisfaction.
• May draft Individualized Plans of Care for review by supervising RN or Licensed Independent Practitioner.
• Other duties, as assigned.

REQUIRED QUALIFICATIONS (Knowledge, Skills & Abilities) :

Education:

• Completion of an accredited Licensed Practical Nurse program.

Licensure:

• Current and unrestricted licensure as a Licensed Practical Nurse (LPN) in the state of Virginia.
• Basic Life Support (BLS) certification from the American Heart Association (AHA) required.

Experience:

• 3+ years professional healthcare experience required; 2+ years of relevant ambulatory or value-based care experience preferred.
• Ability to critically think and apply that knowledge to varying patient needs.
• Proficiency with computers and documentation in the electronic health record.

Skills:

• Demonstrated ability to successfully and productively interface with internal and external partners, including all levels of management, clinical staff and providers, and health plan representatives.
• Requires excellent organizational, problem solving and critical thinking skills.
• Clearly manage issues and communicate resolutions, including appropriate recognition and escalation of clinical concerns outside of scope of practice.
• Intermediate knowledge of and experience utilizing a personal computer, including proficiency in the Microsoft Office Suite (intermediate email, word processing and spreadsheet skills).
• Ability to successfully complete generic and department specific skills validation and competency testing.
• Ability to multi-task, working in a variety of software and internet platforms while conversing with a consumer and documenting information.
• Ability to promptly assess requests by using electronic and paper resource materials and correctly respond to patient inquiries.
• Excellent interpersonal and verbal communication skills, anticipating and responding to customer (internal and external) needs and acting accordingly; and giving high priority to customer satisfaction and customer service.
• Working knowledge of electronic medical record systems, with meticulous data entry and efficient computer navigational skills.
• Requires the ability to prioritize work and perform well when faced with a stressful environment. Maintain ability to be thorough, detail-oriented, and have excellent time management under pressure.
• Must be able to adapt communication to interact positively with individuals of all cultures, all levels of health literacy, and all levels of authority. Empathetic listener, sensitive, upbeat, optimistic, articulate, gracious and tactful. Ability to calm upset patients in a composed and professional demeanor.
• Requires the ability to maintain confidentiality. Self-motivation and ability to work independently within a team setting.
• Adaptable learner with the ability to identify problems and issues of varying complexities and to find effective solutions with few guidelines and proactively addressing situations rather than waiting passively until action is demanded.

PHYSICAL DEMANDS
This is primarily a sedentary job involving extensive use of desktop computers. Hybrid remote work and general office environment, ability to travel between campus buildings, remote facilities, and out of town (regionally) as needed.

The University of Virginia is an equal opportunity employer. All interested persons are encouraged to apply, including veterans and individuals with disabilities. Click here to read more about UVA’s commitment to non-discrimination and equal opportunity employment.