Patient Navigator

Job Description

Neighborhood Health Association (NHA), a Federally Qualified Health Center (FQHC), is the largest community health center system in Northwest Ohio with partnerships that include ProMedica, Mercy Health, and University of Toledo Medical Center. NHA has grown from a single location in 1969 to 12 medical and dental clinics throughout Lucas County. Today we operate multiple health centers including pediatrics, adult medicine, dental services, and health care for the homeless, women’s health center, senior centers and a full service pharmacy with lab services on site.

For more than 50 years, NHA has placed a strong focus on prevention and empowering individual responsibility in managing their health care and overall well-being. Our services are acutely responsive to the needs of everyone throughout the communities we serve, providing excellent care and the best health practices.

General Function:

Under the general supervision of the Social Services Project Manager, the Patient Navigator works in collaboration with the PCMH Care Team. Accepts referrals and manages Provider patient panels. Develops care initiatives to assess and coordinate population specific needs throughout the healthcare system. Responsible and accountable for direct and indirect patient care for designated patient populations. Assesses Social Determinants of Health to eliminate disparities in identification and improvement of service delivery. The Patient Navigator requires expertise in healthcare processes, critical thinking, and problem-solving.

Duties and Responsibilities:

Collaborates in monitoring and assessing Provider patient panels to stratify individual patient risk as well population specific needs to optimize patient engagement and team productivity.

Prepares PCMH Care Teams and individual patients for scheduled visits by conducting individual EHR reviews and patient pre-visit outreach contacts.

  • Assist and facilitate the transition of care from various levels across the healthcare system.
  • Develop comprehensive, collaborative Care Plan, based on Provider treatment plan, evidence based chronic care guidelines, and patient/family goals for patients with chronic conditions and/or recent care transitions to promote treatment acceptance and adherence to Provider recommendations and instructions.
  • Population specific risk management by registry and referral including:

Direct patient care in-person, telephonic, and/or electronic communication.

Provide individual patient/family education and self-management support that is appropriate based on language, cognitive abilities, literacy level, learning style, cultural norms, patient preference, readiness for change and resources available.

Provide individual or group education regarding health conditions, self-management or other population specific topics of healthcare.

Assist patient in creating SMART goals.

Communicate changes in patient’s status appropriately with the Care Team.

Identify barriers when treatment goals are not met, care plan is not followed, or important appointments are missed.

  • Tracks program specific and patient-level quality measures to develop intervention approaches to improve data driven outcomes.
  • Serves as a supportive resource and community referral resource within the practice.
  • Using Electronic Health Record (EHR) system, tracks navigation services, records encounters with patients, and contributes to clinic tracking workflows.
  • Reviews system related tasks and email instructions throughout the day for management of daily responsibilities in order to effectively and thoroughly manage all assigned patient cases to completion.
  • Maintains patient outreach and daily activities for cases assigned to out of office Patient Navigators and peers as directed by leadership team.
  • Adheres to clinic departmental policies and procedures, which include accreditation standards, Trauma Informed Care, Patient Safety initiatives, Patient Rights, and Health Insurance Portability and Accountability Act (HIPAA) Privacy standards.
  • Other duties as assigned.


Bachelor’s Degree in public health, social work, or another related field preferred. Relevant work experience in patient education, nursing, or case management may be considered in lieu of degree.

A valid Ohio driver’s license and auto insurance with an acceptable driving record is required with reliable transportation and willingness to occasional travel throughout Lucas County.

Ability to recognize patients’ and families’ cultural needs/factors that may affect their choices or engagement while communicating with patients and families in a culturally competent manner.

Exceptional writing and personal communication skills is essential to communicate effectively orally, in writing, face-to-face, and over the phone.

Ability to work independently, organize and prioritize predetermined outcomes in order to meet established schedules, timelines, or deadlines.

Experience working with multidisciplinary medical teams and knowledge of Patient Centered Medical Home.

Knowledge of computer functions (Microsoft Suite) to include navigating complex reporting software, use of Electronic Health Record (EHR), and the ability to learn new systems. Must have experience with medical documentation and protection of private health information.

Maintain ethical and professional responsibilities and boundaries.

Excellent benefits including Health, Dental and Vision Insurance, Paid Life Insurance, PTO and 10 paid holidays.

We are a drug free workplace, and an Equal Opportunity Employer.

Our Mission: Through our exceptional health care services, we empower and educate, aggressively working to eliminate health care inequities, while supporting personal responsibility for one’s own health regardless of the ability to pay.

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