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Population Health Transitional Care Management Navigator
4 months ago
Title: Population Health Transitional Care Management Navigator
Department: Population Health & Case Management
Status: Hourly
Position: Classification/Category: Clinical
Location: Coverage & Support for All Medical Sites
Reports To: Population Health Manager
Direct Reports: None
Summary of Position:
The Population Health Transitional Care Management Navigator is responsible for supporting care coordination and clinical quality care gap closure services to Kintegra patients. The Transitional Care Management Navigator will provide individualized assistance to patients to facilitate access to quality care.
The Transitional Care Management Navigator will provide patients with resources to improve their health by identifying and providing access to providers, health education services, community resources, and social support services that will address their individual needs.
The Transitional Care Coordinator will work closely with the Transitional Care Nurse, clinical practices, Providers, contracted programs, and patients to align our initiatives and goals.
Minimum Qualifications and Required Skills
• Medical Assistant (preferred from an accredited program), CNA II, and or CNA I with relevant work experience.
• Excellent interpersonal communication skills.
- Bilingual preferred. (Spanish)
• Strong organizational, analytical and time management skills.
• Strong computer skills/ Data Entry/ EHR documentation and reporting/Utilization of Microsoft Office Suite
• Clinical competence in disease management and care management principles.
• Competence is establishing rapport with patients, providers, and care team.
• Ability to work independently as well as be a team player.
• Knowledge of and compliance with federal and state regulations applicable to the position.
Key Responsibilities:
• Provide patients identified with a clinical quality care gap or receiving case management with access and/or referral to resources to address their needs including providing patient education on chronic disease management, referral to internal Kintegra Health programs available to all patients (MAT, dental, eye clinic, endocrinology, diabetes education, Hepatitis C, HealthNet Gaston, etc.)
• Support and assist Transitional Care Nurse with targeted patient outreach and scheduling based on set timeframes.
• Use motivational interviewing techniques to engage patients and sustain engagement to facilitate compliance with recommended screening/service.
• Assess patients’ barriers to care and resources and assist them with devising solutions to decrease or eliminate those barriers.
• Follow up with patients to ensure resources have been secured and appointments have been kept.
• Provide education and support to encourage patients to use the health care system appropriately.
• Reassess patients to evaluate changes as needed and as appropriate to the treatment plan.
• Provide support for Population Health Team in achieving Clinically Integrated Networks initiatives (Annual Wellness Visits, patient outreach, clinical care gap closure, linkage to resources, medication adherence, Advance Directives).
• Refer patients to the Population Health Transitional Care Nurse other services for issues that fall outside the scope/licensure of the Transitional Care Management Navigator.
• Demonstrate Interpersonal Skills/ Build and Maintain working relationships.
• Maintain understanding of the cultural and socioeconomic backgrounds in the community
• Demonstrate ability to establish effective, trusting working relationships with patients.
• Other duties as assigned.
Physical Demands
• Work in an open office environment, clinical sites and/or work remotely.
• Repetitive wrist motion and occasional lifting/carrying of up to 25 pounds.
• Prolonged periods of sitting, reading and documentation are required
Kintegra Health Core Requirements
1. Patient First – An approach to care that holds primary, the well-being and desires of the patient
2. Build not Blame – Focusing first on finding fault with the process rather than the person
3. Integrity and Honesty – Fostering an acceptance of openness, honesty, and fairness in words, deeds and the use of organizational resources judiciously for both internal and external customers
4. Cooperation and Flexibility – Related to an internal believe that we function as part of an interdependent team with only shared gains or losses thereby committed to assisting whenever possible beyond the prerequisite job description
5. Culturally Sensitive – Always working toward increasing one’s ability to understand, communicate with, effectively interact and care for people across cultures, while having an acute awareness of one’s own culture.
Kintegra Health is a is a community sponsored, family-centered provider of health care, health education and preventive care services without regard to the ability to pay. We screen potential employees to first ensure alignment with our core requirements followed by the requisite position skills set. In doing so we need staff committed to this mission who do their best to live and work the characteristics of our core values as we strive to care for ever increasing members of the communities we serve.
Our goals are:
• To provide continuing comprehensive and accessible primary care services to individuals and families of all economic levels within the counties we serve.
• To provide primary care services to meet the physical as well as social health needs of individuals and families, promoting health maintenance, providing timely diagnostics, treatment and referral services.
• To emphasize preventive care through patient and community education to help individuals become aware and responsible for their own health behaviors.
• To employ an interdisciplinary team approach in collaboration with other community providers to provide a continuum of appropriate patient/family-oriented care in a cost-effective manner.
