Supports the Care Coordinator RN in delivering comprehensive care coordination for Value Based Care patients through proactive outreach and gap closure. Responsibilities include preparing for Medicare Annual Wellness Visits and conducting post-hospital discharge follow-ups to improve health outcomes.
Requirements summary
Requires a high school diploma and a current certificate from an accredited medical assistant or nursing assistant program. Preferred candidates have at least 2 years of experience in a medical office and with EMR systems.
The Care Navigator - Population Health with Choptank Community Health (CCHS) works as a key support to the Care Coordinator (RN) to deliver comprehensive care coordination services for patients, particularly those enrolled in Value Based Care programs. This role focuses on proactive outreach, Medicare Annual Wellness Visit (AWV) preparation, post-hospital and emergency department (ED) discharge follow-up, and Managed Care Organization (MCO) outreach to close care gaps. The Care Navigator facilitates communication, coordinates services, and assists patients in accessing preventive and chronic care services to improve health outcomes. This is a nonexempt, full-time position in pay grade 3 with the pay range of $19.14 - $24.88. The Care Navigator reports directly to the Director of Quality and Population Health.
Education and Experience
High School diploma or equivalent
Certificate of completion from an accredited medical assistant/nursing assistant program
Certificate must remain current.
Minimum 2 years medical office experience preferred
Minimum 2 years EMR system experience preferred Strong communication skills
Strong organizational and time management skills
Basic understanding of medical terminology
Ability to understand and carry out written, oral and/or graphic instructions
Ability to interact with patients, medical and administrative staff, and the public effectively
Intermediate proficiency with computers and telephone use
Positive and proactive attitude; team player!
Goal orientated
Must be punctual and have reliable transportation
Working Conditions and Physical Requirements
General office environment in clinical health centers
Occasional travel
Standards of Behavior
Job Related Competencies
Empathetic Outlook- The ability to perceive and understand the feelings and attitudes of others; the ability to place oneself “in the shoes” of another and to view a situation from their perspective.
Benefits
Health insurance
Dental insurance
Paid holidays
Life insurance
Discretionary bonuses
Vision coverage
Employee assistance program
Employee wellness program
Flexible spending account
Referral program
403(b)
403(b) matching
Tuition and education assistance
Certification scholarships
Flexible paid time off and vacation scheduling
Attention to Detail- The ability to process detailed information effectively and consistently.
Problem Solving- Identifies and analyzes problems weighing the relevance and accuracy of available information. Generates and evaluates alternative solutions and makes effective and timely decisions.
Communicates Effectively- Developing and delivering multi-mode communication that conveys a clear understanding of the unique needs of different audiences.
Values And Ethics- Serving with integrity and respect in personal and organizational practices. Ensuring decisions and transactions are transparent and fair.
Time Management- The ability to effectively manage one’s time and resources to ensure that work is completed efficiently.
Commitment to Community
Choptank Community Health System (CCHS) is committed to creating a safe and open healthcare environment that improves health outcomes and values and respects the unique experiences and perspectives of both patients and staff by:
Prioritizing access for all individuals;
Offering ongoing training for staff to promote health awareness, preventive measures and early detection for the varied patient population on the Eastern Shore;
Actively engaging with patients, families and staff;
Fostering a workplace culture in which everyone is treated with dignity.
Duties/Responsibilities
Support to Care Coordinator RN
Assist in patient identification and outreach for Value Based Care high-risk panels and other targeted populations.
Gather and update patient health history, social determinants of health, and self-management goals for care plan development.
Coordinate with the Care Coordinator (RN) and clinical team to ensure care plans are followed and updated.
Medicare Annual Wellness Visit (AWV) Preparation
Identify eligible Medicare patients and conduct pre-visit outreach to confirm appointments.
Gather necessary health information, screenings, and questionnaires in advance of AWV appointments.
Educate patients on the purpose and benefits of AWVs.
Post-Hospital and Emergency Department Discharge Follow-Up
Monitor daily/weekly hospital and ED discharge reports for assigned Value Based Care patients.
Conduct follow-up calls within required timelines to assess patient status, review discharge instructions, and identify barriers to care.
Notify Care Coordinator (RN) of clinical concerns or urgent needs.
Assist with scheduling follow-up appointments, lab work, or referrals.
MCO Outreach to Close Care Gaps
Perform outreach calls to MCO-assigned patients to schedule overdue preventive screenings, chronic condition follow-ups, and immunizations.
Document all outreach activities and patient responses in the EMR.
Collaborate with MCO case managers and the Care Coordinator (RN) to address care barriers.
Patient Engagement & Resource Navigation
Provide motivational support and health education to promote adherence to treatment plans.
Connect patients with appropriate community resources and social services in collaboration with the Community Health Worker as needed.
Maintain accurate and timely documentation in the patient medical record.
Required to comply with the Health Insurance Portability and Accountability Act (HIPAA) regulations.
Regular, reliable attendance is a requirement of this job.
Benefits
Tuition and education assistance
Certification scholarships available
Paid holidays (9)
Flexible paid time off and vacation scheduling
403(b)
403(b) matching
Employee assistance program
Flexible spending account
Health insurance
Dental insurance
Vision coverage
Life insurance
Referral program
Employee wellness program
Discretionary Bonuses
Choptank Community Health is an Equal Opportunity Employer that does not discriminate based on actual or perceived race, creed, color, religion, alienage or national origin, ancestry, citizenship status, age, disability or handicap, sex, marital or family status, veteran status, sexual orientation, gender identity or expression, genetic information, political affiliation, arrest record, or any other characteristic protected by applicable federal, state, or local laws. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.
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