Population Health Navigator - Accountable Care Organization MFT

Overview

The Population Health Navigator is responsible for promoting effective partnerships between patients/families and the health care team to facilitate care and manage care transitions toward a shared goal model. The Navigator partners with the provider care team to complete annual wellness visits, reduce the severity of chronic disease, and prevent avoidable acute illnesses. The Navigator provides effective clinical health coaching to support self-management of chronic disease and lifestyle changes using care coordination activities and analytics in the ambulatory setting.

• Coordinates the strategic approach to identify new or manage an established patient population
• Collaborates with the provider to develop a plan of care based on identified new and established patient populations
• Completes annual wellness visits on identified population within scope of practice
• Obtains patient consent and assists with enrollment into the Chronic Care Management program
• Observes, reports, and documents medication administration
• Facilitates patient access to appropriate medical and specialty providers as indicated by provider
• Makes referrals to assist patients in meeting goals for proactive wellness
• Provides clinical health coaching interventions to motivate patients and families towards successful self-management

• Cultivates effective partnerships through collaboration with providers, staff and other clinical disciplines to ensure high quality patient care
• Assesses patients for chronic conditions and makes referrals as appropriate
• Collaborates with external resources to assist patients in achieving health goals
• Collaborates with practice leaders to implement effective internal tracking systems for patients
• Ensures all required elements are documented for relevant billing components

Education:

• Associate's Degree
• Bachelor's Degree
• Graduate from an accredited, state approved school of nursing

Experience:

• Two (2) years of experience in clinical nursing role caring for acute or chronic disease patients
• Provider practice or clinic health setting;
  Previous experience in Care Coordination, Case Management, Home Health or Behavioral Health

Skills:

• Strong clinical assessment and critical thinking skills necessary to develop a comprehensive plan of care appropriate for patients with complex medical, emotional and social needs
• Effective organizational, leadership, communication, education, collaboration and counseling skills
• Strong organizational and problem-solving skills

• Job Identification 27476
• Job Category Registered Nurse
• Posting Date 02/05/2026, 08:36 PM
• Job Schedule Full time
• Job Shift Day