Job description
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POSITION INFORMATION
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Promote timely access to appropriate care: Provides post discharge follow-up visits with PCP or Health & Wellness Clinic, ensuring adequate transportation is provided if necessary and follow-up phone call are provided.
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Follow patients once discharged via follow up calls and following up on offered resources to reduce social determinants of health
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Increase utilization of preventative care
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Reduce emergency room utilization and hospital readmissions
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Increase comprehension through culturally and linguistically appropriate education
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Promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s)
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Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals
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Increase patients’ ability for self-management and shared decision-making
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Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs
Position summary:The Navigator Coordinator works in collaboration with the organization's strategic plan and under the supervision of Population Health management, incumbent will provide ongoing, support, facilitation and coordination between new and established physicians and new and existing staff for population health activities across SGMG, Southwest Family Practice and independent practices. The Navigation Coordinator will focus on specific disease states in collaboration/partnership with Nurse Practitioners to follow patients through the continuum. The Navigator will follow populations through post-acute utilization for continuity and transitional handoff to the NP following post-acute discharge. The Navigation Coordinator will collaboratively work with Social Work on the social determinants of health and coordinate appropriate services as necessary, in addition to scheduling follow up care, review length of stay and coordinate services to ensure appropriate plan and discharge of patients.The Navigation Coordinator works at top of his/her scope and in collaboration and continuous partnership with NPs, participating physician offices, chronic care navigators (at home services), patients and their family/caregiver(s), clinic/hospital/specialty providers and staff, hospital-based care team, and community resources in a team approach to: -
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MINIMUM QUALIFICATIONS
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Strong interpersonal skills with a positive "can do" attitude.
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Data analysis experience preferred. Comfortable with technology and familiar with Microsoft Office and other software packages.
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Ability to communicate abstract technical information to less experienced users.
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Ability to lead and facilitate group process.
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Strong analytical skills to trouble shoot and problem solve process issues.
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Excellent written, oral and listening skills.
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Ability to meet flexible work schedule requirements
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N/A
Education:Associates degree or 2 years office experience required.
Required length and type of experience:
Required licensure, certification or registry: -
Location: Southwest General · POPULATION HEALTH-SGMG
Schedule: FULL-TIME, Days, Monday - Friday, 8:30AM - 5:00PM FLEX
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