Health Coach Navigator - Full-time, Day Shift, LPN

Van Diest Medical Center; Webster City (IA); On-site; USD 52,000 - 68,000; Full time

Job summary

Van Diest Medical Center in Webster City, IA seeks a care management professional to support proactive patient care. The role centers on care coordination, registry oversight, outreach, and maintaining high-quality standards in the clinic.

Responsibilities include maintaining the disease registry, generating quality reports, performing data abstraction, and coordinating care with the RN Health Coach and other providers. 36 hours per week (0.9 FTE).

Responsibilities

• Oversees the disease registry database and creates quality performance reports for patient, physician, and clinic levels.
• Performs proactive outreach to patients overdue for visits, labs, or referrals; arranges follow‑ups per protocol.
• Oversees pre-visit chart review by providing disease registry visit manager forms to address gaps in care.
• Assists the RN Health Coach by scheduling appointments or referrals to community resources and educators.
• Performs data abstraction from various electronic systems and supports Medicare Advantage Star programs and other incentives.
• Participates in quality improvement activities and meets regularly with the Care Management Team for ongoing education.

Job description

Performs primarily clerical functions related to the proactive care for patients. Conducts outreach to patients who need care services (care repair) utilizing care guidelines and standing orders to schedule recommended services for disease management patients. Is an integral member of the Van Diest Family Health Clinic team who works to ensure safety, best practice and high quality standards of care are maintained.

• Provides oversight of the disease registry database including:
  a) Assuring database is maintained and kept up-to-date
  b) Creating patient, physician and clinic level quality performance reports
• Provides proactive outreach to patients including:
  a) Identifying patients overdue for visits, labs, referrals and arranging for follow-up services as appropriate.
  b) Identifying patients not meeting clinical goals, such as BP control or glucose control, and arranging for follow-up services by protocol or as appropriate.
• Provides oversight of pre-visit chart review of patients including:
  a) Providing disease registry visit manager form prior to patient office visits so the appropriate clinic staff can identify and address any gaps in care during the office visit.
• Assists with Coordination of Care across the care continuum including:
  a) Assisting the RN Health Coach by making needed appointments or referrals such as to community resources, specialty providers, or disease specific educators.
• Conducts data abstraction from various electronic systems
  a) Assists with Medicare Advantage Star programs as well as other incentive programs

Participates in QI Activities
a) Participates in QI activities
b) Meets on a regular basis with the Care Management Team, as coordinated by VanDiest Medical Center, for information sharing and continuing education activities

36 hours per week (.9 FTE)