Diabetes Equity Patient Navigator

POSITION SUMMARY:The Patient Navigator for the Accelerating Equity in Diabetes program will support patients as they manage their diabetes and hypertension diagnoses. This role will engage patients in appropriate care pathways including pharmacy, dietitian, weight management, and behavioral health visits. The Navigator will perform direct outreach to patients, families, and/or caregivers to provide culturally appropriate follow-up and help connect patients to self-management services across BMC and the broader community. Navigators will also partner with patients to identify and address any barriers or challenges that may prevent access to care.A critical role of the Navigator is to act as the liaison between the patient and their touch points in the healthcare system. The efforts of the Navigator are intended to reduce the burden on the patient and ensure that access to care is timely. In addition to direct patient interaction, the navigator will need to build relationships with care team members to support patients' health goals and priorities.Finally, the Navigator will need to manage a panel of patients engaged with various interventions across the Diabetes care continuum by implementing a population health approach to navigation.Position:

Diabetes Equity Patient NavigatorDepartment:

Pop Health - Value Based CareSchedule:

Full TimeESSENTIAL RESPONSIBILITIES / DUTIES:Patient Navigation & SchedulingServes as a central contact for patients navigating diabetes and hypertension care across the BMC Primary Care practicesConducts outreach and schedules appointments for patients, ensuring that they receive timely reminders and follow-up careUses standardized questionnaires including THRIVE and PAID-5 to identify social determinants of health (SDOH) and diabetes distressAssesses patients' social, financial, and family resources and connects patients to available internal and community resourcesIdentifies resources for transportation, chronic disease self-management, and other patient concernsWorks with patients and caregivers to coordinate services as neededFacilitates the flow of information between patient, provider, and other servicesDocuments patient communication in the Electronic Medical Record (EMR) using encounter notes, in-basket messages, and MyChartWorks with patients to obtain all appropriate medical record informationRefers self-pay patients or patients with insurance issues to Patient Financial Services, as appropriate. Partners with Patient Financial Services to effectively communicate alternative payment options to patientsMeets with patients telephonically or in the clinical settings to navigate them to appointmentsLeverages Motivational Interviewing techniques or similar tools to engage patients and provide emotional support to patients and their families throughout the care journeyAttends trainings and professional development opportunities to maintain knowledge of chronic disease management and available resourcesPatient Tracking & Database ManagementAccurately documents and enters all patient information (i.e., demographics, date of scheduled visits, and barriers) into the patient tracking database and/or Epic EMRVerifies and updates patient insurance information when scheduling any visitsProactively contacts patients to resolve and follow-up on potential barriers for appointment completionProvides general clerical support including: filing, making appointments, photocopying, faxing, preparing and sending mail, making reminder phone calls, and maintaining contacts databaseProgrammatic functions:Identifies system deficiencies and seeks to fill those gaps in collaboration with the program leadEscalates any patient issues to the appropriate team memberDevelops and fosters relationships with other clinic-based navigatorsProvides and receives constructive feedback from team members and patientsContributes to the development of new ideas that impact the programGeneral Duties and Standards:Adapts to changes with departmental needs including but not limited to: offering assistance to other team members, floating, adjusting assignments, etc.Conforms to hospital standards of performance and conduct, including those pertaining to patient rights and HIPAA and privacy rules, so that the best possible customer service and patient care may be providedUtilizes hospital's behavioral standards as the basis for decision making and to support the department and the hospital's mission and goalsFollows established hospital infection control and safety proceduresPerforms other duties as assigned to support overall department prioritiesMust adhere to all of BMC's RESPECT behavioral standards.(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).JOB REQUIREMENTSEDUCATION:A minimum of a High School diploma/GED is requiredEXPERIENCE:Experience working with patients in a healthcare or community-based setting (preferred)Previous customer service experience (preferred)Completed motivational interview (MI) training (preferred)KNOWLEDGE AND SKILLS:Ability to work in a multicultural diverse environment as a member of a health care teamBilingual or multi-lingual skills appropriate to the patient population served (Spanish or Haitian Creole preferred)Strong communication (oral and written), interpersonal, organizational, and record-keeping skillsAbility to handle multiple tasks and responsibilities at the same time effectivelyAbility to work independently and as part of a teamAbility to maintain confidentiality and sensitivity to cultural differencesAbility to understand basic medical terminologyAbility to empathize with and coach patients in navigating the healthcare systemAbility to be flexible and easily adapt to changeKnowledge of software applications such as Microsoft Office and electronic medical record systemsEqual Opportunity Employer/Disabled/Veterans

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