Nursing Support Coordinator Quality

Trinity Health; City of Syracuse (NY); On-site; USD 26,000 - 40,000; Full time

Job summary

Trinity Health in Central New York is seeking a Patient Navigator to support value-based, patient-centered care. You will coordinate care, improve preventive screenings, and engage patients with primary care services to enhance health maintenance.

Working with care teams, you will document activities, support pre-visit planning, quality reporting, and ensure patients adhere to their established medical plans, contributing to better outcomes in a data-driven environment.

Qualifications

• Relevant experience in health care, population health, care management, or related support role.
• Excellent verbal/written communication, interpersonal, problem-solving, and critical thinking skills.
• Proficiency in Microsoft Office (Excel, Access, Word).
• Ability to work autonomously and adjust to changing needs as the role develops.

Responsibilities

• Proactively identifies patients with health maintenance or chronic care management needs.
• Leads patient outreach to ensure health maintenance compliance, especially on preventive services such as annual wellness visits, breast cancer screening, colorectal cancer screening, depression screening, hypertension, and diabetes follow-ups.
• Support primary care pre-visit planning and quality reporting.
• Supports Quality Incentive programs to increase Medicare star rating scores and compliance.
• Supports Clinical Coding Documentation to close gaps in care among target populations.
• Appropriately refers patients to health coach, social work, health home or other staff, as needed.
• Acts as a point of contact for patients and families to facilitates access to primary care and preventive services.
• Other assigned responsibilities as the role develops.
• Reports to System Population Health Performance manager and works in collaboration with primary care teams.

Skills

Verbal communication

Written communication

Interpersonal skills

Problem-solving

Critical thinking

Education

High School Diploma

Bachelor's degree preferred

Medical Receptionist

MA or LPN

Tools

Microsoft Office

Job description

Employment Type:

Full time

Mission Statement:

We, St Joseph’s Health and Trinity Health, serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities.

Vision:

To be world-renowned for passionate patient care and outstanding clinical outcomes.

Core Values:

In the spirit of good Stewardship, we heal by practicing Justice in fostering right relationships to promote common good, Reverence in honoring the dignity of every person, Excellence in expecting the best of ourselves and others; Integrity in being faithful to who we say we are.

Position Summary:

The patient navigator role was developed to support the organization's increasing commitment to value-based and patient-centered health care. The patient navigator assists care teams in improving quality performance and support patient engagement to consistently improve health maintenance needs and coordinate care throughout our Central New York (CNY) Network . Patient Navigator encourage preventive and chronic care management, improves health maintenances documentation in the medical record to support quality reporting, and foster strong patient-provider relationships. The patient navigators facilitate necessary follow-up appointments, preventive screenings, and coordinate with primary care staff to increase patient adherence to their established medical plan. Their work is data-driven and utilizes a population health approach to identify and assist patients and providers to improve health care outcomes.

Patient navigator will focus on key target measures and populations.

• Efficiently engage patients with primary care services. All patients seen at least once a year for an Annual Wellness Visit or follow-up visit with PCP.
• Consistent pre-visit planning review and communication with care team members.
• Close quality gaps in care and updates electronic health record.
• Efficiently support the documentation and follow-up of patients with A1c poor control and Hypertension.
• Improve preventive screenings, such as breast and colorectal cancer screenings, by engaging patients and consolidating results in patient chart.
• Supports quality reporting, supplemental data submission and abstraction.
• Support Clinical Coding Documentation to close gaps in care among high-risk target populations.

Education Requirements:

• High School Diploma, Bachelors preferred. Medical Receptionist, MA or LPN

Experience Requirements:

• Relevant experience in health care, population health, care management, or related support role.
• Excellent verbal/written communication, interpersonal, problem-solving, and critical thinking skills.
• Proficiency in Microsoft Office (Excel, Access, Word).
• Ability to work autonomously and adjust to changing needs as the role develops.

Supervisory Responsibilities:

Number of Staff Supervised: 0

FTE’s Supervised: 0

Job Titles of Staff Supervised:

Level of Supervisory Responsibility (Check all that apply):

X Serves as technical expert to group of peers

Assigns work and schedules time off

Appraises performance

Makes hire, fire, disciplinary, and related decisions

Has budget accountability

Manages through subordinate supervisors

Working Conditions and Physical Requirements:

Code: N-Never; O-Occasionally (<20%); F-Frequently (20%-80%); C-Constantly

Exposure to Adverse Working Conditions:

O Noise, Noxious Odors, Temperatures

O Potentially Threatening Abusive Clients

O Hazardous Materials

O Communicable Diseases

Physical Conditions:

F Close eye Work (computers, typing, reading, writing)

O Sedentary (continuous sitting)

F Light Work (standing, walking, lifting <15 pounds)

F Moderate Work (lifting 15-30 pounds, prolonged use of small hand instruments)

O Moderately Heavy Work (lifting, moving, loading 31-50 pounds)

N Heavy/Hard Work (above average strength and stamina, lifting >51 pounds)

O Heavy/Hard Work (patient handling/lifting, maximum 35 pounds)

Principal Responsibilities:

Duties and Responsibilities:

• Proactively identifies patients with health maintenance or chronic care management needs.
• Leads patient outreach to ensure health maintenance compliance, especially on preventive services such as annual wellness visits, breast cancer screening, colorectal cancer screening, depression screening, hypertension, and diabetes follow-ups.
• Support primary care pre-visit planning and quality reporting.
• Supports Quality Incentive programs to increase Medicare star rating scores and compliance.
• Supports Clinical Coding Documentation to close gaps in care among target populations.
• Appropriately refers patients to health coach, social work, health home or other staff, as needed.
• Acts as a point of contact for patients and families to facilitates access to primary care and preventive services.
• Other assigned responsibilities as the role develops.
• Reports to System Population Health Performance manager and works in collaboration with primary care teams.

Pay Range based on experience and location: $19.20-$28.80

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran