Nursing Support Coordinator

Patient Navigator

Hybrid possible after training Hours 8:00-4:30

Mission Statement: We, St Joseph's Health and Trinity Health, serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities.

Vision: To be world-renowned for passionate patient care and outstanding clinical outcomes.

Core Values: In the spirit of good Stewardship, we heal by practicing Justice in fostering right relationships to promote common good, Reverence in honoring the dignity of every person, Excellence in expecting the best of ourselves and others; Integrity in being faithful to who we say we are.

Position Summary: The patient navigator role was developed to support the organization's increasing commitment to value-based and patient-centered health care. The patient navigator assists care teams in improving quality performance and support patient engagement to consistently improve health maintenance needs and coordinate care throughout our Central New York (CNY) Network. Patient Navigator encourage preventive and chronic care management, improves health maintenance documentation in the medical record to support quality reporting, and foster strong patient-provider relationships. The patient navigators facilitate necessary follow-up appointments, preventive screenings, and coordinate with primary care staff to increase patient adherence to their established medical plan. Their work is data-driven and utilizes a population health approach to identify and assist patients and providers to improve health care outcomes.

Patient navigator will focus on key target measures and populations.

• Efficiently engage patients with primary care services. All patients seen at least once a year for an Annual Wellness Visit or follow-up visit with PCP.
• Consistent pre-visit planning review and communication with care team members.
• Close quality gaps in care and updates electronic health record.
• Efficiently support the documentation and follow-up of patients with A1c poor control and Hypertension.
• Improve preventive screenings, such as breast and colorectal cancer screenings, by engaging patients and consolidating results in patient chart.
• Supports quality reporting, supplemental data submission and abstraction.
• Support Clinical Coding Documentation to close gaps in care among high-risk target populations.

Education Requirements:

• High School Diploma, Bachelors preferred. Medical Receptionist, MA or LPN

Experience Requirements:

• Relevant experience in health care, population health, care management, or related support role.
• Excellent verbal/written communication, interpersonal, problem-solving, and critical thinking skills.
• Proficiency in Microsoft Office (Excel, Access, Word).
• Ability to work autonomously and adjust to changing needs as the role develops.

Supervisory Responsibilities:

Number of Staff Supervised: 0

FTE's Supervised: 0

Job Titles of Staff Supervised:

Level of Supervisory Responsibility (Check all that apply):

X Serves as technical expert to group of peers

Assigns work and schedules time off

Appraises performance

Makes hire, fire, disciplinary, and related decisions

Has budget accountability

Manages through subordinate supervisors

Working Conditions and Physical Requirements:

Code: N-Never; O-Occasionally (<20%); F-Frequently (20%-80%); C-Constantly

Exposure to Adverse Working Conditions:

O Noise, Noxious Odors, Temperatures

O Potentially Threatening Abusive Clients

O Hazardous Materials

O Communicable Diseases

Physical Conditions:

F Close eye Work (computers, typing, reading, writing)

O Sedentary (continuous sitting)

F Light Work (standing, walking, lifting <15 pounds)

F Moderate Work (lifting 15-30 pounds, prolonged use of small hand instruments)

O Moderately Heavy Work (lifting, moving, loading 31-50 pounds)

N Heavy/Hard Work (above average strength and stamina, lifting >51 pounds)

O Heavy/Hard Work (patient handling/lifting, maximum 35 pounds)

Job Specific Competencies

Duties and Responsibilities:

• Proactively identifies patients with health maintenance or chronic care management needs.
• Leads patient outreach to ensure health maintenance compliance, especially on preventive services such as annual wellness visits, breast cancer screening, colorectal cancer screening, depression screening, hypertension, and diabetes follow-ups.
• Support primary care pre-visit planning and quality reporting.
• Supports Quality Incentive programs to increase Medicare star rating scores and compliance.
• Supports Clinical Coding Documentation to close gaps in care among target populations.
• Appropriately refers patients to health coach, social work, health home or other staff, as needed.
• Acts as a point of contact for patients and families to facilitates access to primary care and preventive services.
• Other assigned responsibilities as the role develops.
• Reports to System Population Health Performance manager and works in collaboration with primary care teams.

Pay Range based on experience and location: $19.20-$28.80

Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.