Population Health Patient Navigator

Cornerstone Family Healthcare is actively recruiting for a Population Health Patient Navigator to join our growing team in Cornwall, NY.

Pay

$26.37 per hour

Schedule

Full-time

Location

Cornwall, NY

Mission

Cornerstone Family Healthcare is a non‑profit Federally Qualified Health Center with a mission to provide high quality, comprehensive, primary and preventative health care services in an environment of caring, dignity and respect to all people regardless of their ability to pay. For more than fifty years, Cornerstone has been responsive to meeting the needs of the communities we serve, emphasizing the underserved and those without access to health care regardless of race, economic status, age, sex, sexual orientation or disability.

Benefits

• Competitive salaries
• Health Benefits
• Retirement plan
• Paid Time Off
• Sick Time
• Flexible Spending
• Dependent Care
• Paid Holidays

General Purpose

The Population Health Navigator works directly with providers, care teams, and health plan partners to identify and close care gaps through proactive, preventative outreach. 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.

Responsibilities

• Identify care gaps for patients, including missing preventative screenings, chronic disease monitoring, and recommended well visits.
• Perform proactive preventative outreach, including well visit reminders and follow‑up communication, to engage patients and improve compliance with care recommendations.
• Manage and implement campaigns for targeted outreach, including planning, execution, tracking, and outcome monitoring.
• Coordinate follow‑up care with primary care providers and care teams to ensure continuity of care.
• Collaborate with urgent care providers and interdisciplinary care teams to develop, implement, and support patient care plans.
• 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.

Requirements

• High School Diploma or GED
• Bilingual preferred
• 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.