Patient Navigator - Marshall Health Population Health

Marshall Health•Huntington, WV

About The Position

The Patient Navigator role is within Marshall Health Population Health and focuses on patient engagement, care coordination, population health management, digital health navigation, barrier assessment, and care team collaboration. The navigator will establish relationships with patients, serve as a point of contact, conduct outreach, educate patients on services, and encourage self-management. They will coordinate appointments, facilitate referrals, and ensure continuity of care. A key aspect of the role involves working with patient registries to close gaps in care for various quality measures and value-based programs. Additionally, the navigator will assist patients with digital tools, including patient portals, telehealth, and remote monitoring. They will identify and address patient barriers to care, such as transportation or financial concerns, and refer them to appropriate resources. Collaboration with a multidisciplinary care team is essential, as is accurate documentation within the EHR. The role also includes participation in quality improvement initiatives.

Requirements

High School Diploma or GED required.
Minimum of one (1) year of experience in healthcare, customer service, care coordination, scheduling, or patient services preferred.

Nice To Haves

Associate’s degree in healthcare, business, social services, or related field preferred.

Responsibilities

Establish and maintain positive, trusting relationships with assigned patients.
Serve as a consistent point of contact throughout the patient’s healthcare journey.
Conduct proactive outreach through telephone, text messaging, patient portal, and other approved communication methods.
Educate patients regarding available healthcare services, resources, and preventive care opportunities.
Encourage patient participation and self-management.
Coordinate appointments across primary care, specialty care, diagnostics, and ancillary services.
Facilitate timely referrals and ensure closed-loop communication between providers.
Assist patients with follow-up after emergency department visits and hospital discharge.
Coordinate preventive screenings and recommended follow-up care.
Collaborate with providers and care teams to ensure continuity of care.
Work assigned patient registries to identify and close gaps in care related to Medicare Stars measures, HEDIS quality measures, Medicare Shared Savings Program (MSSP), Value-based payment programs, and Internal quality initiatives.
Assist patients with Patient Portal enrollment and utilization, Telehealth appointment preparation, Remote Patient Monitoring onboarding, Completion of electronic forms and questionnaires, Digital communication tools, and Appointment reminders.
Support Marshall Health Network’s Digital Front Door initiatives.
Identify and assist patients experiencing barriers to care, including Transportation, Financial concerns, Scheduling challenges, Technology access, Health literacy, and Social needs.
Coordinate appropriate referrals to community resources and internal support services.
Work collaboratively with Physicians, Advanced Practice Providers, Registered Nurses, Care Managers, Clinical Pharmacists, Behavioral Health Providers, Dietitians, and Social Workers.
Escalate clinical concerns promptly to licensed healthcare professionals.
Accurately document all patient interactions, outreach activities, barriers, referrals, and outcomes within the electronic health record and designated population health applications.
Maintain complete and timely documentation in accordance with organizational policies.
Participate in initiatives designed to improve Patient access, Quality performance, Preventive care completion, Chronic disease management, Patient experience, Utilization management, and Value-based care outcomes.
Identify workflow improvement opportunities and communicate recommendations to leadership.