Patient Care Navigator- Population Health

Family Practice Asn•Lexington, KY

6h•Onsite

About The Position

We are seeking a dedicated and detail-oriented Care Coordinator / Population Health Assistant to join our healthcare team. This role is responsible for supporting patient care through coordination, follow-up, and quality program management to improve overall health outcomes.

Requirements

A graduate of a Certified Medical Assisting, L.P.N., or R.N. or bachelors’ degree in a health-related field. Current licensure, as appropriate, in the state of Kentucky.
Knowledge of primary care medicine including examination, treatment procedures, etc.
Knowledge of clinical standards, quality assurance and reporting.
Proficient in Word, Excel and other computer programs.
Demonstrate sound judgment and critical thinking skills.
Ability to work independently and collaborate with other team members.
Excellent communication skills, both written and verbal. Ability to listen well and work closely with patients, staff and providers.
Physical ability to sit, stand and stretch repeatedly as well as lift loads of less than 10 pounds.

Nice To Haves

Preferred experience of 1-5 years in a clinical setting, experience with an electronic health record preferred.
Previous experience or knowledge of PCMH, MIPS, ACO’s , HEDIS (quality measures) or other applicable programs preferred.

Responsibilities

Manages various aspects of patient care including medication adherence, gaps in care, referrals, documentation, follow-up on admissions and ER visits, ancillary testing, patient education, etc.
Coordinates continuity of care with external healthcare organizations and facilities, including hospital admissions and discharges to process transition care management (TCM) codes for billing.
Manage patients with high-risk conditions, suspected conditions (HCC- Hierarchical Condition Categories) including patients with multiple co-morbidities or high risk for readmission to a hospital setting.
Maintains an accurate registry of patients within quality programs, including participating in Monthly meetings.
Reviews and generates reports as necessary from quality programs to identify gaps in care and clinical conditions needing appropriate follow-up.
Performs care coordination activities including phone encounters, transition of care follow-up, Chronic Care Management, gaps in cares for all FPA quality programs, nurse visits, referrals, access to community resources and patient education.
Appropriately contacts and engages patients in education and self-management of clinical conditions.
Coordination of Medicare Wellness appointments including scheduling, keeping schedules full for current week (due to cancellations).
Preloads charts for providers for Practitioners Assessment Forms (PAF’s) and submits required documents to programs.
Maintains accurate documentation of conditions, communication, and follow-up care in EHR.
Knowledge of HEDIS/Stars Measures, Patient Center Medical Home and MIPS preferred.
Maintains confidentiality of patient information according to established practice policies and governmental regulations, such as HIPAA.
Participates in committee and staff meetings as required.
Other assigned duties by Population Health Manager or Director of Clinical Care and Population Health as directed.