Value Based Care Patient Navigator

POSITION SUMMARY:

The Value Based Care (VBC) Patient Navigator plays a critical role in supporting BMC primary care patients with preventative and chronic care gaps with an eye toward reducing disparities and improving performance in risk-based contracts. This role combines direct patient outreach with navigation support to ensure patients understand, access, and complete recommended screenings, chronic disease management, and primary care visits. The navigator builds trusted relationships with patients and addresses barriers to care by offering education, coordination, and connections to relevant services.

Position: Value Based Care Outreach Specialist

Department: Value Based Care

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

Patient Navigation & Scheduling

• Serves as a consistent, accessible point of contact for patients with unmet preventive or chronic care needs.

• Educates patients on the importance of services such as primary care visits, A1c and blood pressure checks, screening mammograms, and colorectal cancer screenings.

• Schedules and coordinates appointments across multiple services (e.g., PCP, clinical pharmacy, screening mammograms, lab visits, and colon cancer screenings).

• Helps to prepare patients for appointments by providing clear instructions, collecting external records, and confirming insurance details.

• Helps patients overcome logistical, cultural, and emotional barriers by connecting them to transportation, language interpretation, financial counseling, and community-based resources.

• Provides culturally responsive, empathetic support to patients and caregivers throughout their care journey.

• Escalates clinically complex situations to management as needed.

Patient Tracking & Data Documentation

• Accurately documents patient interactions, outreach outcomes, and patient reported barriers in the electronic medical record (EMR) or provided tracking systems.

• Verifies and updates demographic and insurance information during outreach.

• Monitors patients with open gaps and providers reminder phone calls to ensure appointments are completed.

• Uses patient tracking tools to support reporting and inform care team activities.

Programmatic & Operational Support

• Identifies trends or system-level issues that prevent patients from completing care and collaborates with management to address them.

• Participates in team huddles, case reviews, and feedback sessions to continuously improve navigation efforts.

• Supports initiatives and campaigns designed to improve performance on quality measures and equity goals.

• Builds relationships with primary care teams and other navigators across departments.

General Duties & Standards

• Demonstrates flexibility and readiness to assist team members or adjust responsibilities as needed.

• Follows hospital policies on patient confidentiality, HIPAA, infection control, and safety.

• Upholds hospital behavioral standards and represents the values and mission of the organization.

Performs other duties as assigned to support overall department priorities

Must adhere to all of BMC's RESPECT behavioral standards.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

EDUCATION:

• A minimum of a High School diploma/GED is required.

EXPERIENCE:

• Experience working with patients in a healthcare or community based setting (preferred)

• Previous customer services experience (preferred)

KNOWLEDGE AND SKILLS:

• Strong communication (oral and written), interpersonal, organizational, and record keeping skills

• Must be comfortable using multiple advanced communication tools

• Ability to document work in aprofessional andefficient manner

• Ability to handle multiple tasks and responsibilities at the same time effectively

• Ability to work independently and as part of a team

• Ability to maintain confidentiality and sensitivity to cultural differences

• Ability to be flexible and easily adapt to change

• Knowledge of software applications such as Microsoft Office and electronic medical record systems

• Bilingual or multi-lingual skills appropriate to the patient population served (Spanish or Haitian Creole) are a big plus

Equal Opportunity Employer/Disabled/Veterans

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