Patient Navigator

Reports To: COO

Employee Status: Non-Exempt (Regarding Overtime)

Position Summary: Under general supervision, but in line with established PC&HC policies and procedures, provides ongoing support and expertise through comprehensive assessment, planning, implementation and overall evaluation of individual patient needs. The overall goal of the position is to enhance the quality of patient management and satisfaction, to promote continuity of care and cost effectiveness through the integration and functions of care coordination and to educate patients on PC&HC services.

Essential Functions:

• Assists all patients through the healthcare system by acting as a patient advocate and navigator.
• Participates in Patient-Centered Medical Home team meetings and quality improvement initiatives.
• Supports patient self-management of disease and behavior modification interventions.
• Coordinates continuity of patient care with external healthcare organizations and facilities, including the process hospital admission and discharge and referrals from the primary care provider to a specialty care provider.
• Coordinates continuity of patient care with patients and families following hospital admission, discharge, and ER visits.
• Manages high risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting, including a registry.
• Conducts comprehensive, preventive screenings for patients and/or assists all support staff in daily patient interactions as needed.
• Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
• Facilitates patient medication management based upon standing orders and protocols.
• Participates on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Patient-Centered Medical Home and Medical Neighborhood initiatives.
• Evaluates clinical care, utilization of resources, and development of new clinical tools, forms, and procedures.
• Coordinate pre-visit planning.
• Oversees and manages the Vaccines for Children (VFC) program.
• Monitor medical supply stock and expiration date of medical stock.
• Order medical supplies as needed or directed.

Marginal Functions

• Provide backup coverage for the nursing department as needed.
• Improve the patient experience and health care processes and help assure the provision of high quality health care, as well as an ongoing process of performance improvement.
• Completes all required paperwork
• Perform all other duties as required or assigned.

Requirements

• Licensed and credentialed RN/LPN, other licensed personnel
• Must have in-depth knowledge about current diabetes treatment management.
• Must have knowledge of principles and methods for teaching and instruction for individuals and groups.
• Must communicate with patients in a friendly, positive manner.
• Must be able to operate office related equipment.
• Must follow HIPAA and OSHA requirements.
• A team player that can follow a system and protocol to achieve a common goal
• Highly organized and well-developed oral and written communication skills
• Demonstrates sound judgment, decision-making and problem-solving skills
• Able to maintain confidentiality with all aspects of information in accordance with practice, State and Federal regulations
• Confidence to communicate and outreach to other community health care organizations