Patient Care Navigator

Responsibilities

• Conducts agency visits to client's providers.
• Maintains a caseload as assigned by the Care Coordination Supervisor.
• Utilizes approved Health Home assessment tools and Health Information Technology (HIT) to complete initial and annual assessments and to develop an appropriate care plan of service needs.
• Completes an accurate monthly HML assessment for each assigned member.
• Provides referrals, develops linkages and follows up on client services including timely documentation in all Electronic Medical Records for corresponding Health Homes.
• Uses health Information Technology (HIT) dashboards to link services and communicate among care management team, providers, members and their families/caregivers.
• Conducts member outreach and engagement activities to designated Health Home members, including face-to-face, mail, electronic and telephone contact.
• Ensures that services provided to each member of his/her caseload meets core values of care management services as set forth in federal guidelines of Affordable Care Act.
• Aids members in accessing health care and social service systems including arranging for transportation, scheduling and accompanying member to appointments.
• Helps members in identifying available community-based resources and actively manage appropriate referrals, access, engagement, follow-up and coordination of services.

Qualifications

• Associates Degree in Human Services, Sociology, Psychology or a related field.
• Willingness to travel regularly in the community and to members’ homes as needed.
• Computer literacy including proficiency in Microsoft Office Suite and EHR.
• Experience working directly with people from diverse racial, ethnic and socioeconomic backgrounds.
• Flexibility is needed as members may call outside of daily work schedule (24-hour call).