ACO Palliative Care Navigator

About the role

The Palliative Care Navigator is a clinical navigator within the Population Health Services Organization, accountable to the ACO. The Navigator proactively identifies ACO-attributed patients on a readmission trajectory and delivers upstream palliative navigation — goals-of-care conversations, advance care planning, and coordinated transitions — for readmitted patients, rather than waiting for an inpatient palliative consult to be initiated. Operating under assigned clinical direction and PHSO operational supervision, the Navigator serves as a single, continuous point of contact across inpatient, outpatient, and post-acute settings to ensure palliative and hospice needs are recognized and addressed in a timely manner.

Responsibilities

• Proactively identify ACO-attributed patients on a readmission trajectory.
• Deliver upstream palliative navigation, including goals-of-care conversations, advance care planning, and coordinated transitions for readmitted patients.
• Serve as a single, continuous point of contact across inpatient, outpatient, and post-acute settings to ensure palliative and hospice needs are recognized and addressed timely.
• Operate under assigned clinical direction and PHSO operational supervision.

Requirements

• Active, unencumbered license in the State of Arkansas as either a Registered Nurse (RN) or a Licensed Master Social Worker (LMSW) from a CSWE-accredited program.
• Minimum of 2 years of clinical or patient-facing healthcare experience.
• Valid Arkansas driver's license.

Qualifications

• Bachelor of Science in Nursing (BSN) preferred for RN candidates.
• Licensed Clinical Social Worker (LCSW) preferred for social work candidates.
• Experience in palliative care, hospice, oncology, transitions of care, or care management preferred.
• Experience conducting goals-of-care and advance care planning conversations preferred.
• Familiarity with accountable care organizations, value-based care, or population health initiatives preferred.
• Proficiency with Epic or comparable population health analytics platforms preferred.
• Advanced certification in hospice and palliative care or case management (e.g., CHPN, APHSW-C, CCM) preferred.

Skills

• Strong interpersonal, communication, and documentation skills.
• Ability to manage workload and prioritize independently.

Schedule

Shift: Day; Working Hours: Monday - Friday, 8 am – 5 pm; authorized 80.00 hours bi‑weekly.