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, facilitates patient care, and manages care transitions using a shared-goal model. In partnership with the provider care team, the Navigator completes annual wellness visits, helps reduce chronic disease severity, and works to prevent avoidable acute illnesses. The role provides clinical health coaching to support chronic disease self-management and lifestyle changes that mitigate health risks, using care coordination activities and analytics in the ambulatory setting.

Requirements

Graduate from an accredited, state-approved school of nursing.
Associate's degree and bachelor's degree are listed under Education.
Two years of experience in a clinical nursing role caring for patients with acute or chronic disease.
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

Coordinate the strategic approach to identify new patient populations or manage established populations.
Collaborate with providers to develop plans of care for identified patient populations.
Complete annual wellness visits for identified patients within scope of practice.
Obtain patient consent and assist with enrollment in the Chronic Care Management program.
Observe, report, and document medication administration.
Facilitate access to appropriate medical and specialty providers as indicated by the provider.
Make referrals to help patients meet proactive wellness goals.
Provide clinical health coaching to motivate patients and families toward successful self-management.
Collaborate with providers, staff, and other clinical disciplines to support high-quality patient care.
Assess patients for chronic conditions and make referrals as appropriate.
Collaborate with external resources to help patients achieve health goals.
Collaborate with practice leaders to implement effective internal patient-tracking systems.
Ensure all required elements are documented for relevant billing components.