Population Health Navigator I - Remote in Michigan - McLaren Careers

This position has the ability to work remotely on either a part- or full-time basis as determined by MMG leadership. Candidate must be located in Michigan. The Population Health Navigator directly assists patients with care coordination and promotes patient-centered healthcare delivery within McLaren Health Care and the community. The Population Health Navigator works collaboratively with the MPP care coordination team and health plan care managers to promote optimal patient safety and quality care. This position serves as an initial contact for primary care physicians to refer patients for care coordination and care management services. Essential Functions and Responsibilities: 1. Under the direction of the RN or MSW care coordinator, performs care coordination services for MPP including but not limited to the use of ADT systems, patient outreach, and communication across the care continuum with physician offices, home care providers, hospitals, skilled nursing facilities, and health plans. 2. Conducts initial patient screening for at risk patients based on standardized assessment tools. 3. Refers patients to the appropriate care coordinator based on needs assessment. 4. Establishes trusting relationships with patients and their caregivers while providing general support and encouragement. 5. Identifies and addresses potential patient barriers to care plan adherence. 6. Facilitates timely PCP appointments following discharge from the hospital, ED, or SNF and helps patients overcome barriers to accessing care. 7. Coordinates effective hand-offs from one setting to another including the transmission of health information between providers to ensure safer and more effective care. 8. Coordinates services including diagnostic testing, durable medical equipment, home health, laboratory services, and specialist appointments. 9. Educates patients on appropriate ED use and how to access services within the McLaren Health System. 10. Links patients to community resources and healthcare services when appropriate. 11. Maintains updated community resource database by region. 12. Motivates patients to be active and engaged participants in their healthcare. 13. Conducts outreach to defined populations and assists in scheduling annual wellness visits, follow-up care, and preventive screenings to support physician performance with quality initiatives. 14. Maintains clear and precise documentation of patient care coordination activities. 15. Other duties as assigned or when necessary to maintain efficient operations of the department and the Company as a whole. Required High School Diploma or CMA certification. Five (5) years’ experience in healthcare setting serving chronically ill patients. Preferred: Associate degree in health care or related field. Experience in a health plan or Physician Organization environment with Care Coordination, Utilization Management, disease management, and/or population health. Motivational Interviewing Training.