Patient Care Navigator

The Patient Care Navigator (PCN) renders assistance to patients and professional staff, within an assigned department or centralized geography, in support of improving care access, care transitions and coordination of patient care resources

The PCN works collaboratively with interdisciplinary team members who manage medically or socially complex patient panels

The PCN will actively engage with patients and caregivers through telehealth technology and by phone using critical thinking and communication skills to identify barriers that may be impacting the patient's ability to achieve optimal health

The PCN will facilitate timely access to medical care, and link patients, and families to professional and community resources enabling patients to be active participants in managing their own care.

The PCN provides additional support/education and navigation to both clinical and community resources for patients recently discharged from hospitals and emergency departments

Occasionally, the PCN may meet with patients at locations outside of the MyMichigan Health campus, including the patient's home or a community location.

The PCN may assist with coordinating patient appointments, medical prior authorizations, and conducting patient outreach post discharge

The PCN will work collaboratively with telehub therapists and supervisor to optimize clinical efficiency.

(60%)* Utilize motivational interviewing techniques to identify social risk factors that may be hindering patients from meeting their health care goals

Complete required clinical screenings to assist with identification of patient's risk factors

Link patients to the community, behavioral, and medical resources needed to address social determinants of care and/or barriers to health care goals

Coordinate medical appointments, assist patients in addressing barriers to medication regimen adherence

Work with patients to increase adherence to scheduled appointments, and coordinate follow up with non-clinical services such as transportation, home health help, homeless shelters, home meal delivery, etc

Maintain appropriate documentation of patient contact, referrals made, and services provided.

EXPERIENCE, TRAINING AND SKILLS:

Assist in maintaining a clean and safe environment.

If applicable, may be required to travel to satellite clinics and patient's home or community resources.

Maintain a high level of confidentiality and ensure patient's rights are protected in accordance with proper procedures and in compliance with HIPAA (Health Insurance Portability Accountability Act).

Assist with completing tasks to address the patient's health care plan

Tasks may include, but are not limited to, completing forms, corresponding with community organizations and/or other medical care providers. 

Follow all MyMichigan Health policies and adhere to the current Electronic Medical Record (EMR) workflows to ensure documentation is able to be easily accessed by other team members and reportable for quality initiatives.

Provide for the age specific needs of the population served according to department standards and policies/procedures as evidenced by observation, documentation and peer feedback.

Be empathetic and resourceful to all patients, regardless of their social and/or medical complexities.

Multi?task and facilitate messages, complaints, and urgent calls as appropriate.

Work collaboratively with internal/external health care team members and navigate through the health care system.

Thrive in a moderately paced, urgent need, complex health care environment where the PCN works as a key, valued member of the multidisciplinary team.

Execute both written and verbal instructions.

Review reports and interpret information for prioritization of duties.

Exercise judgment in the application of professional services.

Communicate effectively and serve as a contact person for community partners who have questions about the continuity of care process or need assistance/trouble shooting for their referred patients.