Nursing Support Coordinator

Trinity Health • City of Syracuse, NY

7d • $19 - $29 • Hybrid

About The Position

The patient navigator role was developed to support the organization's increasing commitment to value-based and patient-centered health care. The patient navigator assists care teams in improving quality performance and support patient engagement to consistently improve health maintenance needs and coordinate care throughout our Central New York (CNY) Network . Patient Navigator encourage preventive and chronic care management, improves health maintenances documentation in the medical record to support quality reporting, and foster strong patient-provider relationships. The patient navigators facilitate necessary follow-up appointments, preventive screenings, and coordinate with primary care staff to increase patient adherence to their established medical plan. Their work is data-driven and utilizes a population health approach to identify and assist patients and providers to improve health care outcomes.
Patient navigator will focus on key target measures and populations.
Efficiently engage patients with primary care services. All patients seen at least once a year for an Annual Wellness Visit or follow-up visit with PCP.
Consistent pre-visit planning review and communication with care team members.
Close quality gaps in care and updates electronic health record.
Efficiently support the documentation and follow-up of patients with A1c poor control and Hypertension.
Improve preventive screenings, such as breast and colorectal cancer screenings, by engaging patients and consolidating results in patient chart.
Supports quality reporting, supplemental data submission and abstraction.
Support Clinical Coding Documentation to close gaps in care among high-risk target populations.

Requirements

• High School Diploma, Bachelors preferred. Medical Receptionist, MA or LPN
• Relevant experience in health care, population health, care management, or related support role.
• Excellent verbal/written communication, interpersonal, problem-solving, and critical thinking skills.
• Proficiency in Microsoft Office (Excel, Access, Word).
• Ability to work autonomously and adjust to changing needs as the role develops.

Responsibilities

• Proactively identifies patients with health maintenance or chronic care management needs.
• Leads patient outreach to ensure health maintenance compliance, especially on preventive services such as annual wellness visits, breast cancer screening, colorectal cancer screening, depression screening, hypertension, and diabetes follow-ups.
• Support primary care pre-visit planning and quality reporting.
• Supports Quality Incentive programs to increase Medicare star rating scores and compliance.
• Supports Clinical Coding Documentation to close gaps in care among target populations.
• Appropriately refers patients to health coach, social work, health home or other staff, as needed.
• Acts as a point of contact for patients and families to facilitates access to primary care and preventive services.
• Other assigned responsibilities as the role develops.
• Reports to System Population Health Performance manager and works in collaboration with primary care teams.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED
• Number of Employees: 251-500 employees