Patient Navigator - Marshall Health Population Health

Job Responsibilities:

Patient Engagement

• Establish and maintain positive, trusting relationships with assigned patients.
• Serve as a consistent point of contact throughout the patient’s healthcare journey.
• Conduct proactive outreach through telephone, text messaging, patient portal, and other approved communication methods.
• Educate patients regarding available healthcare services, resources, and preventive care opportunities.
• Encourage patient participation and self-management.

Care Coordination

• Coordinate appointments across primary care, specialty care, diagnostics, and ancillary services.
• Facilitate timely referrals and ensure closed-loop communication between providers.
• Assist patients with follow-up after emergency department visits and hospital discharge.
• Coordinate preventive screenings and recommended follow-up care.
• Collaborate with providers and care teams to ensure continuity of care.

Population Health Management

Work assigned patient registries to identify and close gaps in care related to:

• Medicare Stars measures
• HEDIS quality measures
• Medicare Shared Savings Program (MSSP)
• Value-based payment programs
• Internal quality initiatives

Examples include:

• Annual Wellness Visits
• Colorectal cancer screening
• Breast cancer screening
• Cervical cancer screening
• Diabetic retinal examinations
• Kidney Health Evaluation
• Blood pressure control
• Diabetes monitoring
• Childhood preventive services
• Adult immunizations

Digital Health Navigation

Assist patients with:

• Patient Portal enrollment and utilization
• Telehealth appointment preparation
• Remote Patient Monitoring onboarding
• Completion of electronic forms and questionnaires
• Digital communication tools
• Appointment reminders

Support Marshall Health Network’s Digital Front Door initiatives.

Barrier Assessment

Identify and assist patients experiencing barriers to care, including:

• Transportation
• Financial concerns
• Scheduling challenges
• Technology access
• Health literacy
• Social needs

Coordinate appropriate referrals to community resources and internal support services.

Care Team Collaboration

Work collaboratively with:

• Physicians
• Advanced Practice Providers
• Registered Nurses
• Care Managers
• Clinical Pharmacists
• Behavioral Health Providers
• Dietitians
• Social Workers
• Community Health Workers
• Telehealth Services

Escalate clinical concerns promptly to licensed healthcare professionals.

Documentation

Accurately document all patient interactions, outreach activities, barriers, referrals, and outcomes within the electronic health record and designated population health applications.

Maintain complete and timely documentation in accordance with organizational policies.

Quality Improvement Responsibilities

Participate in initiatives designed to improve:

• Patient access
• Quality performance
• Preventive care completion
• Chronic disease management
• Patient experience
• Utilization management
• Value-based care outcomes

Identify workflow improvement opportunities and communicate recommendations to leadership.