Patient Navigator - Pinehurst Medical : Job Details

Pinehurst Medical Clinic (PMC) PMC is a recognized healthcare provider in the communities of Moore County, Lee County, Cumberland County, Chatham County, and the surrounding six counties. Locally owned and managed, PMC offers a broad range of primary and specialty care services to the communities we serve. The physicians and healthcare team of professionals at PMC share a commitment to patient-centered care that is physician-led and utilizes the latest advances in medical technology. This combination of leading-edge medicine and deep compassion for the people we serve has been a hallmark of PMC since 1952. PMC consists of over 130 providers, approximately 750 employees, and 16 locations. What will you do as a PMC Patient Navigator The Patient Navigator plays a crucial role in our primary care clinic by empowering patients to achieve optimal health and well-being. This position focuses on reducing unnecessary hospitalizations and improving patient outcomes by addressing social determinants of health (SDOH), providing comprehensive patient education, and actively advocating for their needs. The Patient Navigator will be an integral member of the care team, working collaboratively with physicians, APPs, nurses, and other clinic staff to deliver patient-centered, holistic care. A day in the life of a PMC Patient Navigator will include: • Proactive Patient Outreach: Identify and engage patients who would benefit from care management services, particularly those at high risk for hospitalization or with complex medical and social needs. • Comprehensive Needs Assessment: Conduct thorough assessments, including SDOH screening, to identify barriers to health, such as food insecurity, housing instability, transportation challenges, lack of social support, and financial limitations. Utilize clinical knowledge and skills to assess patient health status and identify potential medical needs. Review necessary quality measures to ensure patient isn't falling • Resource Navigation and Referral: Connect patients with appropriate community resources and social services, including food banks, housing assistance programs, transportation services, mental health support, substance use treatment, and other relevant organizations. Develop and maintain a comprehensive and up-to-date resource directory. • Patient Education and Empowerment: Provide individualized education to patients on chronic disease management, medication adherence, healthy lifestyle choices, preventive care, and self-care strategies. Tailor education materials and approaches to meet individual patient needs, literacy levels, and learning styles. Empower patients to actively participate in their care. Use Motivational Interviewing to guide patients through change. • Care Coordination and Collaboration: Actively collaborate with physicians, nurses, pharmacists, and other clinic staff to develop and implement integrated care plans that address patients' medical, social, and behavioral health needs. Facilitate communication and coordination among care providers. Contribute clinical insights and expertise to care planning. • Transitional Care Management: Coordinate with the TCM team and assist in providing timely and effective follow-up with patients after hospital discharge to ensure smooth transitions of care, prevent readmissions, and promote recovery. This could include medication reconciliation, scheduling follow-up appointments, and addressing any emerging needs. Prioritize engaging with patients who come in the office for their hospital follow-up appointment to ensure patient/family understand any provider instruction and how to possibly prevent another episode. • Advocacy and Support: Act as a strong advocate for patients, helping them navigate the healthcare system, access necessary services, and overcome barriers to care. Provide emotional support and encouragement. • Data Collection and Reporting: Maintain accurate and detailed records of patient interactions, SDOH assessments, resource referrals, interventions, and outcomes using the electronic health record (EHR) and other designated systems. Contribute to data collection efforts for program evaluation and quality improvement initiatives. • Community Engagement: Develop and maintain relationships with community organizations and participate in community health initiatives as able to expand access to resources and promote health equity. • Professional Development: Stay current with best practices in patient navigation, community health work, care management, and relevant healthcare regulations through continuing education and professional development activities. Maintain required licensure and certifications. • Performs other duties as assigned. What we can offer PMC is proud to support the total health and well-being of our team members so they can thrive personally and professionally. That's why, as part of the PMC team, you'll have a package of benefits that covers your health, well-being, family, and future. For more information regarding our benefits click here Benefits InformationRequired Qualifications Associate's or Bachelor's degree in public health, health education, medical assistant, nursing, or another related field. Bachelor's degree in Social Work or current and active licensure as a CMA, LPN or RN in North Carolina. Preferred Qualifications One or more years of experience with primary care or other health care setting related to patient advocacy and education. Day Shift, Monday - Friday 40 hours per week