Population Health Care Navigator

Choptank Community Health System, Inc..•Denton, MD

just now•Hybrid

About The Position

The Care Navigator - Population Health with Choptank Community Health (CCHS) works as a key support to the Care Coordinator (RN) to deliver comprehensive care coordination services for patients, particularly those enrolled in Value Based Care programs. This role focuses on proactive outreach, Medicare Annual Wellness Visit (AWV) preparation, post-hospital and emergency department (ED) discharge follow-up, and Managed Care Organization (MCO) outreach to close care gaps. The Care Navigator facilitates communication, coordinates services, and assists patients in accessing preventive and chronic care services to improve health outcomes. This is a nonexempt, full-time position in pay grade 3 with the pay range of $19.14 - $24.88. The Care Navigator reports directly to the Director of Quality and Population Health.

Requirements

High School diploma or equivalent
Certificate of completion from an accredited medical assistant/nursing assistant program
Certificate must remain current.
Strong communication skills
Strong organizational and time management skills
Basic understanding of medical terminology
Ability to understand and carry out written, oral and/or graphic instructions
Ability to interact with patients, medical and administrative staff, and the public effectively
Intermediate proficiency with computers and telephone use
Positive and proactive attitude; team player!
Goal orientated
Must be punctual and have reliable transportation

Nice To Haves

Minimum 2 years medical office experience
Minimum 2 years EMR system experience

Responsibilities

Assist in patient identification and outreach for Value Based Care high-risk panels and other targeted populations.
Gather and update patient health history, social determinants of health, and self-management goals for care plan development.
Coordinate with the Care Coordinator (RN) and clinical team to ensure care plans are followed and updated.
Identify eligible Medicare patients and conduct pre-visit outreach to confirm appointments.
Gather necessary health information, screenings, and questionnaires in advance of AWV appointments.
Educate patients on the purpose and benefits of AWVs.
Monitor daily/weekly hospital and ED discharge reports for assigned Value Based Care patients.
Conduct follow-up calls within required timelines to assess patient status, review discharge instructions, and identify barriers to care.
Notify Care Coordinator (RN) of clinical concerns or urgent needs.
Assist with scheduling follow-up appointments, lab work, or referrals.
Perform outreach calls to MCO-assigned patients to schedule overdue preventive screenings, chronic condition follow-ups, and immunizations.
Document all outreach activities and patient responses in the EMR.
Collaborate with MCO case managers and the Care Coordinator (RN) to address care barriers.
Provide motivational support and health education to promote adherence to treatment plans.
Connect patients with appropriate community resources and social services in collaboration with the Community Health Worker as needed.
Maintain accurate and timely documentation in the patient medical record.
Comply with the Health Insurance Portability and Accountability Act (HIPAA) regulations.
Maintain regular, reliable attendance.