Patient Care Navigator

Summary

The Patient Care Navigator (PCN) renders assistance to patients and professional staff, within an assigned department or centralized geography, in support of improving care access, care transitions and coordination of patient care resources. The PCN works collaboratively with interdisciplinary team members who manage medically or socially complex patient panels. The PCN will actively engage with patients and caregivers through telehealth technology and by phone using critical thinking and communication skills to identify barriers that may be impacting the patient's ability to achieve optimal health. The PCN will facilitate timely access to medical care, and link patients, and families to professional and community resources enabling patients to be active participants in managing their own care.

The PCN provides additional support/education and navigation to both clinical and community resources for patients recently discharged from hospitals and emergency departments. Occasionally, the PCN may meet with patients at locations outside of the MyMichigan Health campus, including the patient's home or a community location.

The PCN may assist with coordinating patient appointments, medical prior authorizations, and conducting patient outreach post discharge. The PCN will work collaboratively with telehub therapists and supervisor to optimize clinical efficiency.

Responsibilities

(60%)* Utilize motivational interviewing techniques to identify social risk factors that may be hindering patients from meeting their health care goals. Complete required clinical screenings to assist with identification of patient's risk factors. Link patients to the community, behavioral, and medical resources needed to address social determinants of care and/or barriers to health care goals. Coordinate medical appointments, assist patients in addressing barriers to medication regimen adherence. Work with patients to increase adherence to scheduled appointments, and coordinate follow up with non-clinical services such as transportation, home health help, homeless shelters, home meal delivery, etc. Maintain appropriate documentation of patient contact, referrals made, and services provided.

(20%)* Effectively and professionally, complete the appropriate work flow & documentation for all assigned patients. Communicates all urgent concerns regarding patient care needs to appropriate care team members in a timely manner.


(15%)* Educate patients on appropriate utilization of healthcare resources. Contribute to the development and management of the patient care plan by actively collaborating with care manager, provider and other team members. If appropriate, shares their personal experience to connect with patients and engender hope and resilience.


(5%)* Participate in process improvement projects and specific clinical tasks as assigned to improve patient access.


OTHER DUTIES AND RESPONSIBILITIES:


Contact patients recently discharged from both inpatient and outpatient treatment for follow up care.

Contact patients with high utilization of emergency behavioral health care and those who may have significant no show rates to identify barriers related to patients reaching their goals.


Assist patients who require clearance (authorization) prior to scheduling appointments.

Assist patients who require specialty care through directly booking appointments where authorized or through working with individual specialty departments to schedule appointments.

Assist patients with education on obtaining community resources to remove their barriers for health care.

Contact patients who have missed medical appointments in order to facilitate future compliance.

Works with patients to understand their challenges with attending patient visits and assist them with securing and meeting a plan to overcome their obstacles.

Effective customer service and communication skills required.

Provide education to patients for health care and community resources.

Demonstrate clinical competencies on an annual basis.

Certifications and Licensures

Certification as a Community Health Worker, Peer Support Specialist or Recovery Coach- Preferred


Required Education

High school diploma or GED is required


Other Information

EXPERIENCE, TRAINING AND SKILLS:


Assist in maintaining a clean and safe environment.

If applicable, may be required to travel to satellite clinics and patient's home or community resources.

Maintain a high level of confidentiality and ensure patient's rights are protected in accordance with proper procedures and in compliance with HIPAA (Health Insurance Portability Accountability Act).

Assist with completing tasks to address the patient's health care plan. Tasks may include, but are not limited to, completing forms, corresponding with community organizations and/or other medical care providers.


Follow all MyMichigan Health policies and adhere to the current Electronic Medical Record (EMR) workflows to ensure documentation is able to be easily accessed by other team members and reportable for quality initiatives.

Provide for the age specific needs of the population served according to department standards and policies/procedures as evidenced by observation, documentation and peer feedback.

Be empathetic and resourceful to all patients, regardless of their social and/or medical complexities.

Multi?task and facilitate messages, complaints, and urgent calls as appropriate.

Work collaboratively with internal/external health care team members and navigate through the health care system.

Thrive in a moderately paced, urgent need, complex health care environment where the PCN works as a key, valued member of the multidisciplinary team.

Execute both written and verbal instructions.

Review reports and interpret information for prioritization of duties.

Exercise judgment in the application of professional services.

Communicate effectively and serve as a contact person for community partners who have questions about the continuity of care process or need assistance/trouble shooting for their referred patients.

Performs other related duties as assigned.

MyMichigan Health is a technology driven organization and employees need to demonstrate competency in Microsoft Windows. An employee may be required to participate in further learning opportunities offered by MyMichigan Health.

PHYSICAL/MENTAL REQUIREMENTS AND TYPICAL WORKING CONDITIONS:


Exposure to stressful situations, including those involving public contact, trauma, grief and death.

Able to wear personal protective equipment including latex materials or appropriate substitute if required for your position.

Able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description.

Overall vision and hearing is necessary with or without assisted device(s).

Frequently required to sit/stand/walk for long periods of time. May require frequent postural changes such as stooping, kneeling or crouching.

Some exposure to blood borne pathogens and other potentially infectious material. Must follow MyMichigan Health bloodborne pathogen and TB testing as required.

Able to handle multiple tasks, get along with others, work independently, regular and predictable attendance and able to stay awake.

Overall dexterity is required including handling, reaching, grasping, fingering and feeling. May require repetition of these movements on a regular to frequent basis.

Physical Demand Level: Light. Must be able to occasionally (0?33% of the workday) lift or carry 11?20 lbs., frequently (34?66% of the workday) 10 lbs. and or Walk/Stand/Push/Pull of Arm/Leg controls.