Community Health Navigator
2 weeks ago
At LifeBridge Health, we are committed to providing exceptional care to our patients. As a Community Care Coordinator, you will play a vital role in promoting the health and well-being of our patients by providing face-to-face and phone outreach, as well as email communications.
Key Responsibilities:
- Accountable for contacting patients, caregivers, and families to ensure preventive services are received by assigned patients.
- Decrease identified care gaps by working with primary care offices to obtain timely appointments for assigned patients, including post-hospital discharge and annual wellness visits where appropriate.
- Understand and apply principles of population health management to identify patients with uncontrolled chronic conditions and/or rising risk indicators and refer to Community Care Manager accordingly.
- Provide care coordination services for patients requiring chronic care management.
- Ensure that appropriate patients receive annual physical exams and/or annual health risk assessments (HRAs) including completion of required documentation by payer contract.
- Evaluate and refer patients to Community Care Manager, as appropriate, when acuity changes.
- Follow treatment plans of patients as written by providers and/or Community Care Managers.
- Assess and assist patients in navigating social and health services, such as enrollment in social security, Medicaid, Medicare, and other appropriate insurance plans.
- Assess and assist patients' safety needs in their homes, including fall risk and ordering equipment where necessary to promote patient independence.
- Assist patients in self-managing their medications, including setting up medication boxes if needed.
- Refer patients or families to community resources for housing or treatment to assist in recovery from chronic illness and follow through to ensure service efficacy.
- Educate and aid family members in understanding, dealing with, and supporting patients with chronic illnesses and end-of-life practices.
- Interview clients about activities of daily living to determine needs and link with community resources where appropriate.
- Review and update provider and Community Care Manager on patients' living conditions and ability to adhere to plan of care and coordinate treatment goals.
- Assess, monitor, and evaluate patients' progress in their homes with respect to treatment goals.
- Document findings in healthcare records following System-approved protocols.
- Perform tasks necessary for collecting data, maintaining records, developing, and utilizing assessment and measuring tools relative to patient care and wellness practices.
- Obtain and coordinate access with primary care providers and other specialty providers, including behavioral health, ensuring necessary records and documentation of referrals are completed and reconciled.
- Educate patients on availability of resources for primary care and acute care, along with alternative community programs and services that promote sound health, lifestyle, and well-being.
- Schedule timely and appropriate office and follow-up visits at or with other healthcare providers, such as dentists, public health, social services, or any other outreach workers needed to provide comprehensive and quality care for patients.
- Be able to work independently with minimal supervision.
- Community outreach activities as assigned.
Requirements:
- Licensed Practice Nurse or Certified Medical Assistant or trained Patient Care Assistant with 2-3 years acute care and/or ambulatory practice experience.
- Preferably with experience working with care managers from acute care settings or health insurance and/or other payer entities.
- Good verbal and communication skills and organizational skills a must.
- Competency in electronic medical records desirable.
- Bi-lingual preferable (market-specific).
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