Job description

Location: 1035 Cambridge Street
Work Days: 8 hours/day, including some evenings
Category: Professional and Management
Department: ASN Crico Grant
Job Type: Full time
Work Shift: Day
Hours/Week: 40.00
Union: No
Union Name: Non Union

DEPARTMENT DESCRIPTION:
CHA’s Health Improvement Team (HIT) works together with healthcare providers, residents, community based organizations and city leadership to assess health status, determine priorities, build action plans and provide leadership around health issues that impact the community.

Summary :
The Care Coordination Program (CCP) Patient Navigator (PN) will work closely with patients, primary care teams and the CCP RN Case Manager to assume responsibilities for outreach, navigation, and care coordination for eligible primary care patients enrolled in the CCP and in need of cancer screening and follow-up testing, diagnosis and treatment. The PN will perform a wide range of functions which safely, effectively, and efficiently support patients and promote increased utilization of Massachusetts Health Quality Partners Recommended breast, cervical and colon cancer screenings according to CHA guidelines. Responsibilities will include enrollment of primary care patients into the program following CCP protocols and guidelines, utilizing clinical information systems, including Epic charts and reports, patient lists, and the DPH WHN/CCP database to guide interventions and track progress. They will review charts to determine patient initial navigation needs, initiate contact with patients and their site care team, assess patient motivation, understanding, and barriers related to preventative screening, work proactively to address and remove barriers which impede access to health care and prevent successful implementation of a treatment plan, build supportive relationships with patients to improve the patient's utilization of necessary health services to improve their health status, provide education and coaching to patients to improve their access and health status, assist uninsured/underinsured patients in the application for public insurance, assist in patient follow up, and refer appropriate patients to RN case management, primary care teams, and/or support services as needed. The PN will document activities and report them to the program manager, primary care teams and RN case manager as needed, maintain program data bases, and recommend program and system improvements based on information gathered during his or her work.

Responsibilities:

• Attends required initial and continuing education/training in area specific topics
• Completes MA DPH required Patient Navigation course within the first 12 months of hire or within 12 months of contract initiation.
• Completes an assessment of assigned enrolled patients via chart review and patient interviews to determine CCP eligibility, obtain consent, determine need for care coordination and navigation. Assessments include review of patient’s insurance status, barriers, motivation, educational needs, cancer screening and follow-up needs, and risk factors.
• Assesses all assigned enrolled patients’ current health insurance status and intervenes directly or by referral when needed to assist with public insurance. Educates patients on ways to self-navigate and self-advocate to maintain appropriate health care coverage.
• Identifies organizational, healthcare system and community resources to support patient navigation activities (e.g. resources for transportation, financial assistance). Maintains up to date list of commonly needed resources and seeks appropriate help to identify less commonly used resources as needed.
• Uses Epic data sources and patient lists to identify patients due or overdue for breast, cervical and/or colon cancer screening. Prepares individualized cancer screening services plan for each patient due for screening.
• Uses information from chart review to tailor outreach strategies to engage patients and prioritize work. Outreaches to patients via phone and in clinic visits to engage them in care and care planning. Uses motivational interviewing strategies to assess and enhance patients’ motivations, understanding, and self-confidence to participate in care plan. Provides culturally and linguistically appropriate education and coaching as needed, tailored to a patient’s stage of change and cognitive abilities.
• Builds a supportive relationship with patient to improve the patient's utilization of necessary primary care, mental health care, and social services to improve the patient's overall health status.
• Partners with patient and other CCP and clinical staff to coordinate cancer screening and follow-up activities through patient navigation. Assists patient in making appointments, schedules appointments directly, assists patients with reminders and supports to reduce barriers as appropriate, and tracks and monitors outcomes.
• Documents all activities and pertinent clinical and navigation information according to program protocol and CHA policies and communicates relevant information to the CCP team and the RN care manager in a timely fashion as required to facilitate navigation.
• Coordinates care planning with RN case manager for patients with an abnormal cancer screening finding. Assists in the coordination and execution follow up plans.
• Provides follow up contact with the patient after cancer screening and diagnostic medical appointments to assess if patients understood and accepted the treatment plan and assist in removing any additional or new barriers to treatments, care plans, and follow up. Outreaches to patients who did not keep appointments to assess barriers and support timely engagement with recommended treatment plan.
• Utilizes clinical information systems daily and uses available information to facilitate timely primary care visits, cancer screening, follow up encounters with clinical team, and patient education programs. Also uses clinical information systems to track, report, and communicate with RN case manager, CCP and clinical teams, and support program reporting.
• Proactively collaborates with multi-disciplinary team, including Planned Care Coordinator and other clinical and non-clinical staff, at primary care practice sites to most effectively reach enrolled patients. Responds to questions and contact from other team members in timely ways.
• Completes data entry into DPH CCP/WHN database on assigned patients to maintain up to date status on a daily basis. Completes additional data entry assignments accurately and in a timely manner.
• Completes required reports on schedule.
• Participates in CCP and CAF team meetings, team projects, and educational programs as assigned.

MINIMUM QUALIFICATIONS:
High energy individual with excellent interpersonal, organizational, and computer skills and a commitment to patient centered care. Effectively interacts with all members of the health care team and with patients. Maintains confidentiality around patient issues. Takes initiative to proactively organize and manage the responsibilities of the job.
Education/Training: Bachelors degree, preferably in human services or a related field strongly preferred.

Language:
Bilingual fluency required (English and Portuguese, Spanish, or Creole). Second language requirement will be determined by the specific cultural/language groups served by PN’s assigned population.
Two years in a relevant human service field in a multi-disciplinary setting; experience with relevant community groups and/or in a multicultural setting preferred.

In keeping with federal, state and local laws, Cambridge Health Alliance (CHA) policy forbids employees and associates to discriminate against anyone based on race, religion, color, gender, age, marital status, national origin, sexual orientation, gender identity, veteran status, disability or any other characteristic protected by law. We are committed to establishing and maintaining a workplace free of discrimination. We are fully committed to equal employment opportunity. We will not tolerate unlawful discrimination in the recruitment, hiring, termination, promotion, salary treatment or any other condition of employment or career development. Furthermore, we will not tolerate the use of discriminatory slurs, or other remarks, jokes or conduct, that in the judgment of CHA, encourage or permit an offensive or hostile work environment.

Cambridge Health Alliance brings Care to the People - including your neighbors, friends and family. Our local hospitals and care centers serve our vibrant, diverse communities, and play an integral role in improving health. As passionate advocates for the underserved, we actively partner with our communities to take on challenging public health issues, and conduct important research to help reduce barriers to care. We believe that everyone deserves access to high quality, convenient health care. This is why our employees believe in where they work and why many build long, rewarding careers at CHA.

Healthcare is changing rapidly. CHA has a strategic plan that charts a proactive course for our future. It is built on a vision of equity and excellence for everyone, every time. It also recognizes that our workforce is our most valuable asset and prioritizes competitive salaries, benefits and professional development opportunities for employees. The strategic plan is changing the way we provide care and improving the health and experience of our patients; we are looking for smart, committed, compassionate people who want to be part of making our vision of better health and equity a reality.

At CHA, you can believe in where you work and go home every day knowing you made a difference. Join our team and help us bring Care to the People.

learninglandscape.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, learninglandscape.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, learninglandscape.com is the ideal place to find your next job.