This position will be at Bedford Medical Arts.

Facilitate integration with the primary care practice team to assure continuity of care and meet the preventative and chronic health needs of patients’ though relationship development, health promotion, collaborative self-management initiatives, and supportive care services.

ACCOUNTABILITIES

1.            Identify chronic and preventative patient needs.

2.            Establish and maintain positive working relationships with all key customers (physicians, office staff, patients, families, and interdisciplinary team). 

3.            Collaborate with primary care practice team and patient to develop plan of care, with respect to ethnic and cultural diversity.

4.            Serve as an essential link between patients and all other care providers.

5.            Engage patient in self-management.

6.            Facilitate appropriate screenings for early disease detection.

7.            Coordinate patient access to necessary services, including community and public health resources. 

8.            Oversee multidisciplinary appointments for consults and support services, including labs, diagnostics, social work, dieticians, etc. and facilitate as needed for optimum health outcomes.

9.            Collaborate with inpatient care management resources to follow patient through care continuum. 

10.         Provide assessment and education utilizing clinically-sound, evidence-based guidelines.

11.         Provide timely, clinical documentation of patient encounters, using the EHR and other tools.

12.         Collect data, track outcomes, and support strategic planning initiatives. 

13.         Attend conferences, trainings, and meetings related to the care navigator program.

14.         Travel to designated physician practices or other health system/community sites, as needed.

15.         Participate in quality improvement initiatives.

16.         Complete special projects, as assigned by leadership team.

17.         Perform other duties as assigned.