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Job description
Job Description
The Population Health Navigator is responsible for promoting effective partnerships between patients/families and the health care team to facilitate care for patients and effectively manage the care transitions to facilitate a -shared goal model-. The Navigator will partner with the provider care team to complete annual wellness visits, assist to reduce the severity of chronic disease and prevent avoidable acute illnesses. The Navigator will provide effective clinical health coaching to assist patients with self-management of their chronic disease and lifestyle changes to mitigate health risk using care coordination activities and analytics in the ambulatory setting.
Responsibilities
Coordinates the strategic approach to identify new or manage an established patient population Collaborates with the provider to develop a plan of care based on identified new and established patient populations.
Completes annual wellness visits on identified population within scope of practice
Obtains patient consent and assists with enrollment into the Chronic Care Management program
Observes, reports, and documents medication administration
Facilitates patient access to appropriate medical and specialty providers as indicated by provider
Makes referrals to assist patients in meeting goals for proactive wellness
Provides clinical health coaching interventions to motivate patients and families towards successful self-management
Cultivates effective partnerships through collaboration with providers, staff and other clinical disciplines to ensure high quality patient care Assesses patients for chronic conditions and makes referrals as appropriate
Collaborates with external resources to assist patients in achieving health goals
Collaborates with practice leaders to implement effective internal tracking systems for patients
Ensures all required elements are documented for relevant billing components
Qualifications
Education: Associate's Degree
Bachelor's Degree
Graduate from an accredited, state approved school of nursing
Graduate from an accredited, state approved school of nursing
Experience: 2
1
Two (2) years of experience in clinical nursing role caring for acute or chronic disease patients
Provider practice or clinic health setting; Previous experience in Care Coordination, Case Management, Home Health or Behavior Health
Skills: Strong clinical assessment and critical thinking skills necessary to develop a comprehensive plan of care appropriate for patients with complex medical, emotional and social needs
Effective organizational, leadership, communication, education, collaboration and counseling skills
Strong organizational and problem-solving skills
Worksite address
gulfport, MS, 39500, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.