Community Health Patient Navigator

POSITION SUMMARY:

Boston Medical Center Health System (BMCHS) is a leading academic medical center with a deep commitment to health equity and a proud history of serving all who come to us for care. BMC provides high-quality healthcare and support, extending beyond our physical campus into our vibrant and diverse communities. As a core member of the Boston Medical Center Health System, BMC is advancing medicine and training the next generation of healthcare providers and researchers.

In 2021 BMC launched the "Health Equity Accelerator" with the purpose of 'transforming healthcare to deliver health justice and well-being'. The Accelerator, in partnership with Population Health, is developing an innovative multi-disciplinary approach that combines clinical operations, community engagement, health-related social needs programs, and research assets to address racial health inequities.

The Navigator will serve as the patient's guide throughout the program and is responsible for supporting patients in the management of their conditions (hypertension, diabetes, and obesity). This role will perform direct outreach to patients, families, and/or caregivers to provide culturally appropriate follow-up. Navigators will also partner with patients to identify and address any barriers or challenges that may prevent access to care and connect them with the appropriate care team members. A critical role of the Navigator is to act as the liaison between the patient and the program care team. As the liaison, the Navigator will help to distill medical information delivered from care team members down into digestible "plain language" to assist the patient in managing their condition. To manage this effectively, the Navigator will need to build relationships with care team members to support patients' health goals and priorities.

This role requires strong communication skills, emotional intelligence, and a commitment to advancing health equity.

Position: Community Health Patient Navigator

Department: MGB Diabetes Initiative

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

Patient navigation and scheduling

• Serves as a central contact for patients navigating diabetes, hypertension, and obesity care in the program
• Conducts outreach to engage patients in program and conducts intake appointment in partnership with the Nurse Practitioner
• Schedules appointments for patients, ensuring that they receive timely reminders and follow-up care
• Uses standardized questionnaires including (e.g., THRIVE and PAID-5) to identify social determinants of health (SDOH) and diabetes, hypertension, and obesity related distress
• Assesses patients social, financial and family resources and connects patients to available program and community resources in partnership with the other program team members
• Works with patients and caregivers to coordinate services as needed
• Facilitates the flow of information between patient, provider and other program team members and distills medical information down into "digestible plain language"
• Documents patient communication in the Electronic Medical Record (EMR) using encounter notes, inbasket messages and MyChart
• Meets with patients telephonically or in community settings to navigate them to appointments
• Leverages Motivational Interviewing techniques or similar tools to engage patients and provides emotional support to patients and their families throughout the program
• Manages a panel of patients engaged in various stages of the program
• Attends group programming to support patient cohorts
• Attends trainings and professional development opportunities to maintain knowledge of chronic disease management and available resources
• Presents patient cases during team huddles succinctly and logically

Patient tracking and database management

• Accurately documents and enters all patient information (i.e., demographics, date of scheduled visits and barriers) into the patient tracking database and/or epic EMR
• Verifies and updates patient insurance information when scheduling any visits
• Proactively contacts patients to resolve and follow-up on potential barriers for appointment completion
• Provides general clerical support including filing, making appointments, photocopying, faxing, preparing and sending mail, making reminder phone calls, and maintaining contacts database
• Facilitates distribution of patient's remote monitoring devices and provides teaching
• Ensures patient's remote monitoring data is flowing into the EMR and troubleshoots any issues that arise

Programmatic functions

• Identifies system deficiencies and seeks to fill those gaps in collaboration with the program lead
• Escalates any patient issues to the appropriate team member
• Develops and fosters relationships with other community-based programs and care team members
• Provides and receives constructive feedback from team members and patients
• Contributes to the development of new ideas that impact the program

General 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 provided
• Utilizes hospital's behavioral standards as the basis for decision making and to support the department and the hospital's mission and goals
• Follows established hospital infection control and safety procedures

Performs other duties as assigned to support overall program priorities

Equal Opportunity Employer/Disabled/Veterans