Patient Navigator - Marshall Health Population Health

Marshall Health•Huntington, WV

About The Position

Marshall Health is seeking a dedicated Patient Navigator to join their Population Health team. This role focuses on patient engagement, care coordination, and population health management to improve patient outcomes and support the organization's digital health initiatives. The Patient Navigator will work with assigned patient registries to identify and close gaps in care, assist patients with navigating the healthcare system, and collaborate with various care team members to ensure comprehensive patient support.

Requirements

Experience in patient engagement, care coordination, or population health management.
Familiarity with healthcare services, resources, and preventive care.
Ability to conduct outreach through various communication methods (telephone, text, patient portal).
Skills in coordinating appointments and facilitating referrals.
Experience with patient registries and quality measures (e.g., Medicare Stars, HEDIS).
Proficiency in assisting patients with digital health tools (patient portal, telehealth, remote monitoring).
Ability to identify and address patient barriers to care.
Strong collaboration and communication skills for working with diverse care teams.
Proficiency in electronic health records (EHR) and population health applications.
Understanding of quality improvement principles.

Nice To Haves

Experience with Digital Front Door initiatives.
Knowledge of specific quality measures such as Annual Wellness Visits, Colorectal cancer screening, Breast cancer screening, Cervical cancer screening, Diabetic retinal examinations, Kidney Health Evaluation, Blood pressure control, Diabetes monitoring, Childhood preventive services, and Adult immunizations.

Responsibilities

Establish and maintain positive, trusting relationships with assigned patients, serving as a consistent point of contact throughout their 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, encouraging patient participation and self-management.
Coordinate appointments across primary care, specialty care, diagnostics, and ancillary services, facilitating timely referrals and ensuring closed-loop communication.
Assist patients with follow-up after emergency department visits and hospital discharge, and 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, and completion of electronic forms and questionnaires.
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, coordinating appropriate referrals.
Work collaboratively with physicians, advanced practice providers, registered nurses, care managers, clinical pharmacists, behavioral health providers, dietitians, social workers, community health workers, and telehealth services.
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.