Patient Navigator

Description

Position Overview:

Under the direction of the Chronic Care Manager, the Patient Navigator provides care coordination, health education, and health promotion services to address barriers to care and ensure that patients have access to and obtain needed medical, behavioral health and social services to optimize their health status.  This work is carried out in support of the mission and goals of Ryan Health.

Essential Functions:    

Care Coordination

1. Reviews referrals and assesses patients for individual patient navigation/care management services.
2. As part of a care team model, collaborates and consults with other team members in identifying service gaps and other patient needs.
3. Develops, implements, and reassesses care plans to address barriers to expected health outcomes and self-management and to address patient needs and assures continuity of care.
4. Screens and assists patients on eligibility for entitlements, such as legal, social and support services, utilizing tools such as PRAPARE and other assessment tools.
5. Advocates and negotiates services on behalf of patient, family and significant others, in accordance with Center policies and procedures.
6. Ensures coordination and follow-up of medical, psychiatric and social services including appointments, referrals, and other consultations.
7. Documents services in a timely and robust manner consistent with agency standards including the use of the Center’s electronic health record.

Outreach & Enrollment

1. Provides home, hospital, or community site visits and escorts patients to medical and non-medical appointments, as indicated and as approved by the Chronic Care Manager.
2. Conducts outreach at direction of the Population Health Department, which may include patients that have disengaged or are at risk of disengaging from care and individuals whose psychosocial stressors are limiting their success in achieving healthy outcomes and who can benefit from patient navigation.
3. Participates with  Population Health Department and Ryan Health in developing and implementing strategies to reach target populations.
4. Develops linkages between community agencies and resources to ensure continuity of care.

Documentation & Quality Assurance

1. Maintains patient records in accordance with agency protocols and standards using Ryan’s electronic medical record system.
2. Participates in Quality Improvement/Performance Improvement (QI/PI) teams and tasks, as assigned by the Department of Population Health.

Policies, Procedures, & Compliance

1. Attends required meetings, case conferences, supervision, trainings, Ryan events, and professional conferences as assigned.
2. Immediately reports any problems or unusual occurrences to the Chronic Care Manager.
3. Special projects and other duties as assigned.

Competencies Required:

Customer Service:

• Professional, courteous, respectful, and non-judgmental attitude in dealing with patients
• Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served (if applicable)
• Embraces harm reduction model
• Commits to exceeding expectations of the patient, including feasible services beyond those outlined in job description

Cooperation/Teamwork

• Works well with others
• Contributes input to improve outcomes
• Asks others for opinions and feedback, provides feedback in a tactful & respectful way

Qualifications

Education, Experience and/or Skills Required:

1. HS Diploma or High School Equivalency
2. Effective communication and writing skills. 
3. Proven track record of organization, attention to detail and ability to respond promptly to requests, and anticipation of organizational needs.
4. Computer literate with proficiency in standard office software/hardware such as Microsoft Word, Excel, Outlook, PowerPoint.

Education, Experience and/or Skills Preferred:

1. Bachelor’s Degree in Social Work, Health Education, Counseling, or related field.
2. 2 years relevant experience working with a population with chronic conditions in a medical setting.
3. Knowledgeable of community resources as pertinent to social determinants of health (e.g. housing, food access, transportation, et al)
4. Other language proficiency: Spanish, Arabic, Bengali, Urdu, Russian, French

Salary : $37 - $41