Community Health Patient Navigator

POSITION SUMMARY:

The Patient Navigator  is responsible for providing advocacy and case management services for patients, facilitating access to social service benefits and other internal and external resources, and advocating on behalf of the patient. The Patient Navigator is also responsible for guiding patients through the health care system and ensuring that patients and members are able to access culturally and linguistically appropriate services in a timely and cost effective manner. The Patient Navigator helps patients arrive at scheduled appointments on time and prepared for specific procedures. Facilitates interaction and communication with health care staff and providers. Offers educational materials in appropriate language. These activities requires the Patient Navigator to properly document care plans in the electronic medical record, and to be knowledgeable about community resources, including financial, educational, social, and emotional support services available to patients. The Patient Navigator shall demonstrate cultural competency with respect to the patient populations served and will track patients through completion of all diagnostic and treatment plans to ensure timely receipt of care.

Position: Community Health Patient Navigator        

Department: MGB Diabetes Initiative

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

Patient navigation and scheduling

• Serves as a central contact for patients navigating diabetes, hypertension, and obesity care in the program
• Conducts outreach to engage patients in program and conducts intake appointment in partnership with the Nurse Practitioner
• Schedules appointments for patients, ensuring that they receive timely reminders and follow-up care
• Uses standardized questionnaires including (e.g., THRIVE and PAID-5) to identify social determinants of health (SDOH) and diabetes, hypertension, and obesity related distress
• Assesses patients social, financial and family resources and connects patients to available program and community resources in partnership with the other program team members
• Works with patients and caregivers to coordinate services as needed
• Facilitates the flow of information between patient, provider and other program team members and distills medical information down into “digestible plain language”
• Documents patient communication in the Electronic Medical Record (EMR) using encounter notes, inbasket messages and MyChart
• Meets with patients telephonically or in community settings to navigate them to appointments
• Leverages Motivational Interviewing techniques or similar tools to engage patients and provides emotional support to patients and their families throughout the program
• Manages a panel of patients engaged in various stages of the program
• Attends group programming to support patient cohorts
• Attends trainings and professional development opportunities to maintain knowledge of chronic disease management and available resources
• Presents patient cases during team huddles succinctly and logically

Patient tracking and database management

• Accurately documents and enters all patient information (i.e., demographics, date of scheduled visits and barriers) into the patient tracking database and/or epic EMR
• Verifies and updates patient insurance information when scheduling any visits
• Proactively contacts patients to resolve and follow-up on potential barriers for appointment completion
• Provides general clerical support including filing, making appointments, photocopying, faxing, preparing and sending mail, making reminder phone calls, and maintaining contacts database
• Facilitates distribution of patient's remote monitoring devices and provides teaching
• Ensures patient’s remote monitoring data is flowing into the EMR and troubleshoots any issues that arise

Programmatic functions

• Identifies system deficiencies and seeks to fill those gaps in collaboration with the program lead
• Escalates any patient issues to the appropriate team member
• Develops and fosters relationships with other community-based programs and care team members
• Provides and receives constructive feedback from team members and patients
• Contributes to the development of new ideas that impact the program

General Duties and Standards

• Adapts to changes with departmental needs including but not limited to offering assistance to other team members, floating, adjusting assignments, etc.
• Conforms to hospital standards of performance and conduct, including those pertaining to patient rights and HIPAA and privacy rules, so that the best possible customer service and patient care may be provided
• Utilizes hospital’s behavioral standards as the basis for decision making and to support the department and the hospital’s mission and goals
• Follows established hospital infection control and safety procedures

Performs other duties as assigned to support overall program priorities

Equal Opportunity Employer/Disabled/Veterans