Population Health Patient Navigator

Cornerstone Family Healthcare•Town of Cornwall, NY

just now•Onsite

About The Position

Cornerstone Family Healthcare is actively recruiting for a Population Health Navigator to join our growing team in Cornwall, NY. This role supports member management initiatives with payers, coordinates and implements targeted outreach campaigns, and assists in care plan training and reporting (PMCH and PVP) to improve patient engagement, care quality, and overall health outcomes. Join a patient-centered team that uses proactive outreach to keep our community healthier. As a Population Health Navigator, you will work directly with providers, care teams, and health plan partners to identify and close care gaps, increase preventive screenings, and improve follow-through on chronic care. In this role, you will coordinate targeted outreach campaigns, manage patient reminder calls and letters, and help patients schedule overdue preventive and chronic care visits. You will also support payer member-management initiatives, validate data for quality reporting, and contribute to quality improvement efforts that enhance patient engagement and outcomes.

Requirements

High school diploma or GED.
Experience in healthcare setting, preferably urgent care or primary care.
Highly organized with excellent oral and written communication skills
Ability to maintain a non-judgmental disposition and communicate with a diverse population.

Nice To Haves

Bilingual Preferred

Responsibilities

Identify care gaps for patients, including missing preventive screenings, chronic disease monitoring, and recommended well visits.
Perform proactive outreach (calls, reminders, letters) to engage patients and help them complete needed services.
Coordinate targeted outreach campaigns and track outcomes and follow-up.
Collaborate with primary care, urgent care, and interdisciplinary teams to support and document patient care plans.
Support payer quality initiatives, data validation, and population health quality improvement projects.
Support member management activities with payers, including outreach related to managed care organization (MCO) rosters and payer-driven quality initiatives.
Assist with PMCH care plan training and reporting, ensuring accurate documentation, tracking, and compliance with program requirements.
Support PVP training and collaboration with care teams to promote consistent workflows and understanding of quality measures.
Ensure timely completion of important health screenings, including cancer screenings and other preventative services.
Conduct follow-up phone calls and outreach to schedule appointments for overdue preventative or chronic care services.
Send reminder letters and conduct outreach during overdue service campaigns.
Validate and maintain accurate data for reporting, quality metrics, and population health management purposes.
Participate in and/or coordinate Quality Improvement initiatives related to data collection, training, and process improvement.
Monitor patient outcomes and assist in adjusting workflows to improve engagement and health outcomes.
Educate patients on the importance of preventative care and adherence to follow-up appointments.
Attend scheduled departmental, All Staff, and required meetings.
Maintain compliance with HIPAA regulations and organizational confidentiality policies.
Perform other related duties as assigned.