SUMMARY OF JOB FUNCTION
As a member of the Gardner Downtown Resource Center and a Complex Care Management team the Patient Health Navigator will work directing support to Gardner Family Health Network’s (GFHN) highest risk patients who are experiencing one or more chronic disease conditions, in addition to ongoing medical and social barriers. The Patient Health Navigator will be part of a multi-disciplinary team comprised of primary care providers, RN Complex Care Manager, and LVN. In collaboration with this team, the Patient Health Navigator outreach for patients and provide coordination to a variety of support systems to patients including care coordination and care management services to GFHN patients, Whole Person Care referrals, and those who reside within the Downtown San Jose Service Area.
ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES:
• High-risk assessments questionnaire and with patient input, develops low-risk care plans under RN and LVN Complex Care Manager that integrate medical, psycho-social, and financial issues that impact the health and well-being of patients and their families.
• In collaboration with the primary care physician, the RN Complex Care Manager and care team, monitors patient’s response to the individualized care plan and updates care plan as needed or per case dispositions in weekly team huddles.
• Establishes close working relationships with patients with the goal of creating partnerships that will help the client work toward complying with their care plans and ultimately become more proactive in their managing their own health.
• Promotes whole-person care by supporting patients in managing their individual physical health issues and providing health education in one-to-one and/or group settings.
• Works closely with physicians and behavioral health therapists to support the clients coordinated care and will support counseling staff in implementing treatment plan.
• Utilizes behavioral strategies to help patients adopt healthier behaviors and improve self-care in chronic disease management. Promote self-management goals.
• In collaboration with other staff, assists patients in navigating the health care system, follows-up on test results and other care coordination needs.
• Performs ongoing evaluation and documentation of patient progress/ risk status in EHR; regular communication with care team.
· Medical Assistant Certificate and/or Patient Navigator Certificate preferred.
· Two-years of equivalent work or life experience with low income populations with multiple needs, chronic diseases, or other health conditions.
· Bilingual English/Spanish preferred.
· Ability to work with a diverse ethnic and multi-cultural population.
· Computer skills including proficiency in medical practice management systems, internet use, and Microsoft office applications.
· Strong communication and conflict resolution skills.
· Excellent written and verbal communication skills.
· Ability to set and meet deadlines.
· Creative and flexible team player with a sense of humor. Must be comfortable in a fast-paced environment.
· Ability to take instruction yet work independently and take initiative.
· Demonstrates effective problem solving skills and uses proper communication channels until the problem is solved.
· Demonstrated working knowledge of OSHA and HIPAA guidelines.
· In performing the functions of this position, incumbent is required to have manual dexterity, sitting, standing, stooping, reaching, kneeling, bending, talking, walking and hearing and be able to lift 25lbs
EQUAL EMPLOYMENT OPPORTUNITY:
It is the policy of Gardner Family Health Network, Inc. to provide equal employment opportunity to all people without regard to race, color, ancestry, religious creed, national origin, disability, medical condition, gender, age, sexual orientation or marital status.