MA, POPULATION HEALTH NAVIGATOR

Monday - Friday 8 AM - 4:30 PM

Company Overview

The Population Health Navigator is responsible for engaging patients through telephone, text messaging, patient portal, and other approved communication methods to promote preventive health services, improve chronic disease management, and support value-based care initiatives.

This position works collaboratively with clinic staff, providers, care teams, and health plans to identify and address patient care gaps, educate patients, facilitate access to recommended services, and support improved health outcomes. The Population Health Navigator plays an important role in meeting organizational quality goals and performance measures.

Job Summary

Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude these from the position if the work is similar, related, or is a logical assignment to the position.

1. Conduct outbound patient outreach to individuals due for preventive screenings, immunizations, annual wellness visits, chronic disease follow-up, and other recommended healthcare services.

2. Respond to inbound calls from patients returning outreach calls and assist with scheduling or other appropriate needs.

3. Schedule patient appointments directly in the electronic medical record (EMR) according to provider scheduling guidelines and accurately identify and document the reason for the visit.

4. Educate patients regarding the importance of preventive care, chronic disease management, medication adherence, and recommended healthcare services.

5. Document all patient outreach, education, scheduling activities, and follow-up accurately and timely within the electronic health record (EHR).

6. Coordinate with providers, nurses, medical assistants, care coordinators, and other clinic staff to promote continuity of care and completion of identified care gaps.

7. Monitor patient follow-through with recommended care and conduct appropriate follow-up for missed appointments, incomplete screenings, or unresolved care gaps.

8. Identify potential barriers to care, including transportation, financial, social, or other needs, and connect patients with appropriate internal or community resources when available.

9. Reconcile scheduled appointments on a daily basis to identify patient attendance and determine whether identified care gaps were addressed during the visit.

10. Collaborate closely with CommuniHealth clinic teams to support Population Health outreach workflows and quality improvement efforts.

11. Support patient engagement strategies designed to improve preventive care utilization, chronic disease outcomes, and quality measure performance.

12. Maintain patient confidentiality and comply with HIPAA, organizational policies, and applicable federal and state regulations.

13. Support quality improvement initiatives related to HEDIS, STAR Ratings, MIPS, CMS quality measures, ACO initiatives, and other value-based care programs.

14. Participate in department and team meetings, workflow improvement activities, quality initiatives, and ongoing education and training.

15. Perform other duties and responsibilities as assigned.

Qualifications

1. Certified Medical Assistant (CMA) or comparable clinical experience preferred.

2. Experience working in Population Health, value-based care, or an Accountable Care Organization (ACO).

3. Familiarity with HEDIS measures, CMS quality measures, STAR Ratings, MIPS, and other value-based performance measures.

4. Experience with Chronic Care Management (CCM), Transitional Care Management (TCM), and/or Remote Patient Monitoring (RPM).

5. Experience working with health plans, payer quality programs, or care-gap outreach initiatives.

6. Experience with patient engagement, motivational interviewing, or care coordination.

Skills/Experience:

1. Excellent interpersonal and patient engagement skills.

2. Strong telephone communication and customer service skills.

3. Ability to build rapport and establish trust with patients.

4. Knowledge of motivational interviewing and patient-centered communication techniques.

5. Ability to educate and motivate patients to participate in recommended healthcare services.

6. Strong organizational and time-management skills.

7. Excellent attention to detail and accuracy in documentation.

8. Ability to follow established workflows and meet productivity and quality expectations.

9. Critical thinking, problem-solving, and decision-making skills.

10. Ability to recognize barriers to care and assist patients in identifying appropriate resources.

11. Ability to work effectively as part of a multidisciplinary healthcare team.

12. Compassionate, professional, and patient-centered approach.

Environmental/Working Conditions:

1. Works in a well-lighted/ventilated office area of the facility.

2. Is subject to frequent interruptions.

3. Is involved with personnel, patients, visitors, government agencies/personnel, etc., under all conditions/circumstances.

4. Is subject to hostile and emotionally upset personnel, patients, visitors, etc.

5. Is willing to work beyond normal working hours: weekends holidays, and other shifts/positions as necessary.

6. Attends and participates in continuing educational programs designed to keep you abreast of changes in your profession.

7. Is subject to cuts, bruises, falls, burns from equipment, odors, etc., throughout the workday.

8. Occasional overtime may be required and/or hours may be shortened as business needs dictate.

Physical Demands:

1. Must be able to handle occasional lifting and pulling.

2. Must be able to move intermittently throughout the work day.

3. Must be able to speak the English language in an understandable manner.

4. Must be able to cope with the mental and emotional stress of the position.

5. Must be able to function independently, have personal integrity, and the ability to work effectively with patients, personnel, and support agencies.

6. Must be able to relate to and work with ill, disabled, elderly, emotionally upset, and at times hostile people within the facility.

7. Possible exposure to blood-borne pathogens.

This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, skills and working conditions may change as needs evolve.

EOE

Benefits:

• 403(b)
• Dental insurance
• Disability insurance
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Professional development assistance
• Referral program
• Retirement plan
• Vision insurance

Work Location: In person

Salary : $35,673 - $51,625