PAT NAVGTR NON-CLIN 3 CX

% 

of time

Essential Function (Yes/No)

Key Responsibilities

(To be completed by Supervisor)

30

Core Responsibilities

• Patient Outreach & Engagement

• Care Coordination & Navigation

• Health Education & Self-Management Support

• Resource Connection & Barrier Resolution

• Documentation & Information Management

• Collaboration & Team-Based Care

• Quality & Professional Practice

25

Care Gap Closure/Care Coordination

• Creates rapport with patients with sickle cell disease primarily through telephonic outreach, while also providing in-person support when needed.
•  Conducts outreach to assess care needs, schedule appointments, support care gap closure, and serve as a point of contact for patients requiring follow-up and care coordination.
• Supports closure of preventive and disease-specific care gaps and facilitates timely access to specialty and primary care services.
•  Provides education regarding sickle cell disease, preventive care, treatment adherence, and available support services.

• Collaborates with providers, care teams, and community partners to improve patient engagement and health outcomes

15

Longitudinal Care Management 

• Provides ongoing care management, health coaching, and self-management support for patients with sickle cell disease.
• Utilizes Motivational Interviewing techniques to promote behavior change and support achievement of individualized health goals.
• Reinforces provider-directed care plans, treatment recommendations, and disease management strategies.
• Monitors patient progress identifies barriers to care and facilitates problem-solving.

• Provides education related to sickle cell disease, treatment options, medications, pain management strategies, and self-management practices.

15

Care Coordination & Patient Navigation

• Coordinates care across providers, clinics, departments, hospitals, and community organizations to support continuity of care for patients with sickle cell disease.
•  Assist patients with appointment scheduling, reminders, transportation, medication access, referrals, and linkage to internal and external resources.
•  Coordinates transitions of care between inpatient, outpatient, emergency department, and specialty care settings.
•  Serves as a liaison between patients, caregivers, providers, care teams, community-based organizations (CBOs), and community partners.
• Collaborates with local and state initiatives, the Sickle Cell Center of Excellence (SCCoE) Community Advisory Board (CAB), and community-based organizations to connect patients with appropriate resources, services, events, and support programs.

• Triages patient questions and facilitates resolution of administrative, financial, and clinical concerns.

10

Quality Improvement

• Documents patient interactions, outreach activities, and interventions in the electronic health record and outreach tracking systems.
•  Maintains registries, reporting tools, and data collection processes to support quality metrics and program evaluation.
•  Supports quality improvement initiatives, workflow development, and implementation of best practices for sickle cell disease care.
•  Maintains current knowledge and participates in ongoing education related to sickle cell disease, emerging research, treatment advancements, and available local and state resources through attendance at conferences, trainings, and meetings.

• Serves as a subject matter expert for assigned sickle cell workflows, resources, and community partnerships. Education related to sickle cell disease, emerging research, treatment advancements, and available local and state resources through attendance at conferences, training, and meetings.

Serves as a subject matter expert for assigned sickle cell workflows, resources, and community partnerships

5

Other duties as assigned

• Perform additional responsibilities as assigned to support departmental and organizational goals.

100%