QI-VBC Patient Navigator

Position Summary

The Patient Navigator supports population health and care coordination efforts within a Federally Qualified Health Center by engaging attributed patients assigned through Managed Care Organizations (MCOs), improving access to preventive and primary care services, and assisting patients with Medicaid eligibility maintenance, recertification, and reenrollment. This role helps advance value-based care goals by reducing barriers to care, improving patient outcomes, and supporting continuity of insurance coverage. This is a 6-12 month position.

• ESSENTIAL DUTIES AND RESPONSIBILITIES Assist patients with Medicaid recertification, renewal applications, and reenrollment processes.
• Educate patients on required documents, deadlines, and eligibility requirements.
• Help patients’ complete applications and submit supporting documentation.
• Conduct outreach to patients attributed through Medicaid Managed Care Organizations (MCOs) to schedule primary care visits, annual wellness visits, preventive screenings, and follow-up appointments.
• Contact patients by phone, text, mail, and community outreach methods to encourage engagement in care.
• Educate patients on available health center services, benefits, and care coordination resources.
• Track outreach attempts and patient responses in the EMR (EClinicalWorks) and payer reporting systems.
• Assist in closing care gaps related to preventive screenings and chronic disease management.
• Monitor attributed patient panels to identify overdue services and support provider quality metrics.
• Collaborate with care teams to improve patient compliance with treatment plans and recommended services.
• Support initiatives tied to value-based payment contracts and quality performance targets.
• Identify social barriers affecting healthcare access, including transportation, food insecurity, housing instability, and language needs.
• Facilitate and schedule patient appointments/referrals and connect to internal/external community resources.
• Work closely with providers, case managers, social workers, and front desk staff to ensure continuity of care.
• Maintain accurate documentation of outreach, enrollment assistance, and patient encounters.
• Generate reports on outreach outcomes, recertification completion, and quality improvement efforts.