Population Health Navigator

About the role

The Population Health Navigator works closely with primary care providers and the broader health‑care team to assess patient needs, connect individuals with community resources, and advocate for optimal service delivery. This full‑time position focuses on chronic disease management, care transitions, and patient education to improve health outcomes.

Key responsibilities

• Collaborate with providers to oversee chronic disease registries and develop individualized care plans.
• Facilitate smooth transitions from inpatient, rehabilitation, and skilled‑nursing settings to outpatient care.
• Provide patient and family education tailored to language, literacy, cultural norms, and readiness for change.
• Address medication adherence, identify barriers to care, and arrange follow‑up appointments, labs, and referrals.
• Communicate changes in patient status to the care team and conduct after‑visit summary reviews.
• Utilize standing orders and clinical protocols to deliver care and report on quality measures.
• Liaise with insurance companies for patients with chronic illnesses.
• Serve as a clinical and community‑resource reference for staff and patients.

Required profile

• Strong understanding of health‑care processes and chronic disease management.
• Excellent critical‑thinking and care‑coordination abilities.
• Ability to work collaboratively within multidisciplinary teams.
• Capacity to perform essential functions with or without reasonable accommodation.

Required skills