Phamily Hiring for Chronic Care Navigator at Remote Full Time

Chronic Care Navigator

The Chronic Care Navigator is a medical assistant who supports the development of patient-centered, team-based care. S/he will support primary care physicians (PCPs) and practices in managing their panel of patients using a population management informatics tool. By gathering and organizing patient data, the Chronic Care Navigator works to identify patients’ unmet needs, engage patients in their own care, gather summary information for treatment interventions, and enhance ongoing communication between the patient and her/his care team. The goal of the Chronic Care Management program is to facilitate high-value, patient-centered care that improves timely access to and provision of preventive services and chronic disease treatment.

KEY AREAS OF RESPONSIBILITY:

• Develops a keen understanding of primary care practice requirements for optimal, coordinated population health
• Works as an effective team member of the care team
• Works a Chronic Care Management platform to support patients with multiple chronic diseases and assists in coordination of the patients care continuum.
• Contributes to quality improvement and care redesign of population health efforts

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Manage patient registries and provide the members of health care teams in designated practices with the data required to meet the health needs of the patient
• Support practice staff to develop interventions to proactively manage target populations
• Contributes to a positive experience for patients and families through courteous telephone and digital interactions, accurate and expeditious routing, as well as referral to appropriate clinical staff when necessary
• Recognize and data inconsistencies to appropriate personnel
• Contributes to the teamwork within and between departments. Regularly attends and participates in meetings with coworkers and practice staff.
• Perform all job functions in compliance with applicable federal, state, local and company policies and procedures
• And other duties as assigned

QUALITY IMPROVEMENT AND PROCESS DESIGN

• Collaborate with care teams to establish population-appropriate, pre-visit, and point of care processes
• Provide data to the care teams to properly perform these processes
• Monitor and correct patient attribution to the practice and the care teams within the practice
• Minimum of 3 years experience in primary care setting or similar specialty. Experience in population health preferred
• Proven problem-solver with ability to multi-task
• Prior use of electronic health records and other health care information systems desirable

QUALIFICATIONS

• Certified Medical Assistant from nationally recognized organization preferred
• Significant experience within a primary care setting with quality/population health experience in lieu of certification will be considered.

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