Population Health Navigator-Accountable Care Organization-Days-MFT

Memorial Hospital at Gulfport•Biloxi, MS

About The Position

The Population Health Navigator promotes effective partnerships between patients and families and the health care team to facilitate care and manage transitions using a shared-goal model. The Navigator partners with the provider care team to complete annual wellness visits, reduce the severity of chronic disease, and prevent avoidable acute illnesses. In the ambulatory setting, the Navigator provides clinical health coaching to help patients manage chronic conditions and make lifestyle changes that mitigate health risks, using care coordination activities and analytics.

Requirements

Associate's degree or bachelor's degree.
Graduation from an accredited, state-approved school of nursing.
Two years of experience in a clinical nursing role caring for patients with acute or chronic diseases.
Strong clinical assessment and critical-thinking skills to develop comprehensive plans of care for patients with complex medical, emotional, and social needs.
Effective organizational, leadership, communication, education, collaboration, and counseling skills.
Strong organizational and problem-solving skills.

Nice To Haves

Experience in a provider practice or clinic health setting.
Previous experience in care coordination, case management, home health, or behavioral health.

Responsibilities

Coordinates the strategic approach to identify new or manage an established patient population.
Collaborates with providers to develop plans of care for identified patient populations.
Completes annual wellness visits for identified patients within scope of practice.
Obtains patient consent and assists with enrollment in the Chronic Care Management program.
Observes, reports, and documents medication administration.
Facilitates patient access to appropriate medical and specialty providers as indicated by the provider.
Makes referrals to help patients meet proactive wellness goals.
Provides clinical health coaching to motivate patients and families toward successful self-management.
Collaborates with providers, staff, and other clinical disciplines to support high-quality patient care.
Assesses patients for chronic conditions and makes referrals as appropriate.
Collaborates with external resources to help patients achieve health goals.
Collaborates with practice leaders to implement effective internal patient-tracking systems.
Ensures all required elements are documented for relevant billing components.