PATIENT CARE NAVIGATOR

The Patient Care Navigator at Riverside Healthcare provides essential administrative and clinical support to nurses, social workers, and the management team within the Population Health/Quality department. This role is pivotal in coordinating patient care and ensuring adherence to established care management processes and demonstrates flexibility with assignments within professional scope/duties/licensure. The Patient Care Navigator will work to enhance patient outcomes through effective communication, coordination, and support, extending beyond the Population Health program to various other areas of care.

Essential Duties

Patient Monitoring and Outreach:

• Daily monitoring of payer portals and reports to identify inpatient discharges, Emergency Room discharges, and other high-risk patients.
• Provide outreach and assistance to patients, facilitating care flows according to established policies and procedures.
• Conduct follow-up outreach to ensure patients attend scheduled appointments, including transitional care visits.

Documentation and Communication:

• Document all patient communication and related activities in the Epic system and payer portals as required.
• Monitor and review revenue, compliance, and communicate with Site Supervisors regarding appointment schedules.

Care Coordination:

• Collaborate with patients and interdisciplinary care teams to address barriers to adherence, including transportation, food insecurity, social services, and financial concerns.
• Act as a liaison to multiple departments, agencies, and provider offices, including but not limited to Loving Lift, inpatient social services, Home Health Care, Primary Care, and specialty clinics.

Quality and Compliance Management:

• Monitor, evaluate, and document monthly care management readmissions and utilization of Home Health Care, Mobile Integrated Health, and Loving Lift transportation.
• Identify, outreach, and follow up with patients to address gaps in preventative health maintenance and perform quality measure care gap outreach.

Patient Education and Support:

• Educate patients on managing their diagnoses effectively at home, such as COPD stoplight education.
• Serve as the primary point of contact for patients with chronic special needs or identified high-risk cases needing care management services.

Administrative Support:

• Mail, collect, scan, and assist customers in completing health risk assessments.
• Provide additional administrative support as needed.

Non-essential Duties

• Assist with other administrative duties as assigned.
• Participate in departmental meetings and contribute to process improvements.

Preferred Experience

• Strong written and verbal communication skills.
• Exceptional interpersonal skills with the ability to engage with patients and interdisciplinary teams effectively.
• Proven ability to multi-task and manage a diverse workload.
• Intermediate proficiency with Microsoft Office programs.
• Ability to function independently, organize tasks, and be self-motivated. 
• Previous experience in an ambulatory care setting.
• Experience with Electronic Medical Records (EMR) systems, Epic experience preferred.
• Bilingual skills highly desirable

Required Licensure/Education

• High School Diploma or GED required 

Preferred Education

• Associates degree preferred. 

Employee Health Requirements

Exposure/Sensory Requirements

Exposure to: 

• Chemicals: White out for correction of typing/writing corrections. 
• Video Display Terminals: Average 
• Blood and Body Fluids: Low risk 
• TB or Airborne Pathogens: Low risk. 

Sensory requirements (speech, vision, smell, hearing, touch):

• Speech: Required to communicate with physicians, hospital staff, and outside agencies. 
• Vision: Needed to perform chart review data, computer screen work, reading data and information. 
• Smell: NA 
• Hearing: Needed for telephone communication and communication with team members 
• Touch: Needed to write, computer entry, individual pages of chart for review. 

Activity/Lifting Requirements 

Percentage of time during the normal workday the employee is required to:

• Sit: 70% 
• Twist: 2% 
• Stand: 10% 
• Crawl: 0% 
• Walk: 9% 
• Kneel: 1% 
• Lift: 4% 
• Drive: 0% 
• Squat: 1% 
• Climb: 0% 
• Bend: 2% 
• Reach above shoulders: 1% 

The weight required to be lifted each normal workday according to the continuum described below:

• Up to 10 lbs: Not Required 
• Up to 20 lbs: Not Required 
• Up to 35 lbs: Not Required 
• Up to 50 lbs: Not Required 
• Up to 75 lbs: Not Required 
• Up to 100 lbs: Not Required 
• Over 100 lbs: Not Required 

Describe and explain the lifting and carrying requirements. (Example: the distance material is carried; how high material is lifted, etc.): 

Maximum consecutive time (minutes) during the normal workday for each activity:

• Sit: 120 
• Twist: 1 
• Stand: 30 
• Crawl: 0 
• Walk: 10 
• Kneel: 1 
• Lift: 5 
• Drive: 0 
• Squat: 1 
• Climb: 0 
• Bend: 2 
• Reach above shoulders: 1 

Repetitive use of hands (Frequency indicated): 

• Simple grasp up to 10 lbs. 
• Normal weight: 80% 
• Pushing &pulling Normal weight: 
• Fine Manipulation: Computer entry, writing. 

Repetitive use of foot or feet in operating machine control: None 

Environmental Factors & Special Hazards

• Environmental Factors (Time Spent): 
• Inside hours: 8 
• Outside hours : 0 
• Temperature: Normal Range 
• Lighting: Average 
• Noise levels: Average 
• Humidity: Normal Range 
• Atmosphere: Odors, Dust 
• Special Hazards: NA 
• Protective Clothing Required: None