Patient Care Navigator

Identifies care navigation needs and implements effective action plans for the patient who may have:

• Behavioral health conditions
• High cost/high utilization
• Poorly controlled or complex conditions
• Social determinants of health and/or other barriers to care
• Referrals to or from outside organizations (e.g., insurers, health system, ACO), practice staff, patient/ family/caregiver
• Care gaps and preventative health needs
• Special population status with unique needs
• Other identified circumstances/needs

Will assist with patient visits to support the patient and practitioner needs.

Acts as a patient advocate internally and with outside agencies.

Coordinate all aspects of completing referrals, imaging ordered by providers. (i.e., obtain pre-procedure authorizations and insurance authorizations).

Communicates directly with patients to inform them of their appointment with an outside organization or specialist, reminds them of upcoming appointments, and follows-through with the accepting provider to ensure the patient attended the appointment.

Tracks referrals until the accepting organization or specialist report is available.

Tracks imaging tests until results are available.

Assesses barriers a patient may have for an upcoming appointment (i.e., transportation). If barriers are uncovered, seek community resources that may be offered to assist the patient.

Informs the referring practitioner if a patient does not attend an appointment to receive further guidance on how to proceed.

Monitors open orders to ensure orders are closed out in a timely manner, and links documents to referral if necessary.

Make appropriate notations in the medical records through the referral process.

Maintain specialty provider list including payor sources they accept.

Establishes person-centered action plans for patients identified for care navigation services and communicates the plan effectively to the patient/family/caregiver.

Identifies patients with unplanned inpatient admissions and ER visits shares clinical information and ensures contact with patients/families/caregivers for follow-up care.

Provides patient education and supports the patient/family/caregivers in self-management, self-efficacy, and behavior change, acting as a liaison between the practitioner and patient.

When indicated, coordinates patient’s care with other providers and settings and communicates needed information.

Develops and maintains positive working relationships with external healthcare providers and agencies to ensure effective referral of patients and effective communication.

Involves care team staff in regular care team meetings and structured communication processes focused on individual patient care.

Maintains complete, accurate, and confidential medical records. Documents in the EMR all care navigation activities, education, referrals, and consultations consistent with EHFM procedures and state regulatory standards.

Participates in QM&I, risk management, and critical incident review activities.

Assist with monitoring quality measures/indicators related to patient care and participates in solutions.

Maintains strict confidentiality, ensuring all patient information remains confidential following the HIPAA privacy policies and the minimum necessary standard.

Works as a member of the interdisciplinary team, using a participatory style of service delivery, to provide quality service to all EHM patients.

Attend required meetings and participates in committees as requested. Participate in professional development activities.

Performs pre-visit planning tasks as assigned.

Meet with patients in person, via telephone or video.

Site rotation for work assignments as necessary.

Builds and maintains knowledge of community resources.

Participates in new employee orientation.

Completes or attends mandatory in-services for CPR, Infection Control, Domestic Violence, Mandated Reporter, and others as assigned.

Collects and reports data as requested.

Education and Experience:

• High School Diploma
• Human Service/Public Health or related degree preferred.
• Minimum of three years’ experience related to Care Navigation/Care Coordination or relevant healthcare related experience.

Job Type: Full-time

Pay: $20.00 - $25.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Vision insurance

Medical Specialty:

• Primary Care

Schedule:

• 5x8
• 8 hour shift
• Day shift
• Monday to Friday
• No weekends

Work Location: In person

Salary : $20 - $25