Population Health Transitional Care Management Navigator

Kintegra Health•Gastonia, NC

About The Position

The Population Health Transitional Care Management Navigator is responsible for supporting care coordination and clinical quality care gap closure services to Kintegra patients. The Transitional Care Management Navigator will provide individualized assistance to patients to facilitate access to quality care. The Transitional Care Management Navigator will provide patients with resources to improve their health by identifying and providing access to providers, health education services, community resources, and social support services that will address their individual needs. The Transitional Care Coordinator will work closely with the Transitional Care Nurse, clinical practices, Providers, contracted programs, and patients to align our initiatives and goals.

Requirements

Medical Assistant (preferred from an accredited program), CNA II, and or CNA I with relevant work experience.
Excellent interpersonal communication skills.
Strong organizational, analytical and time management skills.
Strong computer skills/ Data Entry/ EHR documentation and reporting/Utilization of Microsoft Office Suite
Clinical competence in disease management and care management principles.
Competence is establishing rapport with patients, providers, and care team.
Ability to work independently as well as be a team player.
Knowledge of and compliance with federal and state regulations applicable to the position.

Responsibilities

Provide patients identified with a clinical quality care gap or receiving case management with access and/or referral to resources to address their needs including providing patient education on chronic disease management, referral to internal Kintegra Health programs available to all patients (MAT, dental, eye clinic, endocrinology, diabetes education, Hepatitis C, HealthNet Gaston, etc.)
Support and assist Transitional Care Nurse with targeted patient outreach and scheduling based on set timeframes.
Use motivational interviewing techniques to engage patients and sustain engagement to facilitate compliance with recommended screening/service.
Assess patients’ barriers to care and resources and assist them with devising solutions to decrease or eliminate those barriers.
Follow up with patients to ensure resources have been secured and appointments have been kept.
Provide education and support to encourage patients to use the health care system appropriately.
Reassess patients to evaluate changes as needed and as appropriate to the treatment plan.
Provide support for Population Health Team in achieving Clinically Integrated Networks initiatives (Annual Wellness Visits, patient outreach, clinical care gap closure, linkage to resources, medication adherence, Advance Directives).
Refer patients to the Population Health Transitional Care Nurse other services for issues that fall outside the scope/licensure of the Transitional Care Management Navigator.
Demonstrate Interpersonal Skills/ Build and Maintain working relationships.
Maintain understanding of the cultural and socioeconomic backgrounds in the community
Demonstrate ability to establish effective, trusting working relationships with patients.
Other duties as assigned.