Health Promotions Navigator (68524)

VARIETY CARE INC•Oklahoma City, OK

31d•Onsite

About The Position

The Health Promotion Navigator supports the Population Health and clinical care teams by utilizing patient-level data, outreach, and care coordination strategies to close care gaps, improve preventative health outcomes, and increase patient engagement. This role focuses on identifying patients with unmet health needs, addressing psychosocial barriers to care, and ensuring accurate documentation to support population health, quality, and value-based care initiatives.

Requirements

One or more years of clinical experience as an LPN, or three or more years of clinical experience as a Medical Assistant, or five years of experience in a clinic setting with demonstrated care coordination experience.
Excellent oral and written communication skills.
Knowledge of medical terminology and clinical documentation standards.
Ability to interpret and act on population health data, registries, and dashboards at the patient and panel level.
Proficiency with electronic health records, including accurate documentation to support care gap and quality reporting.

Nice To Haves

Bilingual (English/Spanish).

Responsibilities

Care Gap Identification & Patient Outreach Coordinates closure of preventative and chronic care gaps for targeted patient populations.
Reviews population health registries, dashboards, and reports to identify patients with outstanding care gaps and prioritize outreach activities.
Identifies patients without upcoming appointments who have unmet care needs and contacts patients to facilitate care gap closure, including scheduling primary care visits when appropriate.
Conducts outreach to assigned attributed patients who are not currently engaged in care at Variety Care.
Patient Education & Navigation Educates patients on health literacy topics, with emphasis on preventative screenings and chronic disease management.
Utilizes motivational interviewing and patient-centered, trauma-informed approaches to explore and address psychosocial barriers impacting care plan adherence.
Refers patients, within scope, to internal services as needs are identified (e.g., WIC, Community Health Navigator, Care Access Coordinators, etc.).
Coordinates with Community Health Navigators to assist patients with applications for assistance programs related to preventative screenings (e.g., colorectal screening support for uninsured patients).
Clinical Documentation & EHR Use Reviews patient encounters retrospectively to identify incomplete health maintenance items and assists with closing care gaps not addressed during visits.
Follows up on pending preventative screening orders and referrals generated during patient encounters.
Enters orders into the electronic health record for screening tests, labs, or imaging in accordance with approved standing orders.
Maintains accurate, timely, and complete documentation in the electronic health record to support care gap reporting, payor requirements, and population health initiatives.
Data Utilization & Reporting Support Utilizes population health and quality dashboards to identify care gaps with the greatest potential to improve patient outcomes.
Reviews and validates patient-level data in the electronic health record to ensure accuracy of preventative screening status, health maintenance alerts, and outreach documentation.
Demonstrates working knowledge of core quality and value-based care measures relevant to assigned populations (e.g., cancer screening, diabetes control, tobacco cessation).
Supports assigned payor and population health reporting activities through accurate documentation, outreach tracking, and data validation tasks.
Identifies documentation or workflow issues that negatively impact care gap reporting and escalates concerns to Population Health or Quality leadership as appropriate.
Team Collaboration & Performance Improvement Facilitates care team sessions to review care gap and HCC coding performance data, identify patient-level barriers, and share effective outreach strategies.
Shares best practices across clinics to improve consistency in outreach, documentation, and care gap closure workflows.
Collaborates with the Quality team to align outreach activities and documentation practices with organizational quality goals, while not owning measure definitions or external reporting submission.
Assists in identifying patients with complex needs who may benefit from referral to care management services.
Attends Population Health team meetings and participates in performance discussions as assigned.
Compliance & Organizational Support Follows Universal Precautions and uses appropriate personal protective equipment as required.
Adheres to HIPAA regulations and Variety Care policies related to patient privacy and confidentiality.
Complies with Occupational Safety and Health Administration (OSHA) workplace safety standards.
Supports Variety Care’s accreditation as a Patient-Centered Medical Home and commitment to providing care that is Safe, Effective, Patient-Centered, Timely, Efficient, and Equitable.
Embodies high ethical standards, accountability, adaptability, and sound judgment while serving as a result-oriented problem solver.
Performs other duties as assigned.