Patient Outreach & Care Navigator

Redwoods Rural Health Center (RRHC) is looking for a Patient Outreach & Care Navigator to work in our fun, friendly and fast paced clinic located in Redway, CA. The Patient Outreach & Care Navigator works in close collaboration with the Primary Care Team and the Quality Improvement Department to support both clinical operations and population health efforts. This role blends Medical Assistant responsibilities with proactive panel management and patient outreach. The Patient Outreach & Care Navigator assists with coordination, managing patient panels with a focus on increasing chronic disease care coordination, specifically diabetes and hypertension, as well as preventive screenings.

The Patient Outreach & Care Navigator is responsible and accountable for conducting direct and indirect patient outreach, working from patient lists to close care gaps and improve health outcomes. The role helps identify Social Determinants of Health–related needs and coordinates appropriate resources, referrals, and follow-up to reduce barriers and improve access to care. Success in this position requires strong knowledge of healthcare workflows, excellent communication skills, critical thinking, and effective problem-solving.

ESSENTIAL FUNCTIONS

Primary Care Team Support

Proactively review and scrub patient charts to identify and actively close care gaps related to chronic disease management and preventive screenings.

Perform care coordination activities, including follow-up on provider recommendations, assisting with referrals, and supporting patients in completing needed services.

Conduct diabetic retinal imaging, blood pressure checks, and diabetic foot exams.

Perform basic clinical tasks such as point-of-care testing (e.g., A1c fingerstick) and blood pressure measurements (training provided).

Assist in administering patient questionnaires and screeners (e.g., ASQ-3, PHQ-9, SDOH) and manage appropriate follow-up workflows.

Schedule patients directly for recommended services, chronic disease follow-ups, and preventive care appointments.

Serve as a supportive resource within the practice, assisting staff and providers with care coordination, workflow needs, and patient engagement efforts.

Communicate with patients to reinforce care plans, encourage engagement in preventive services, and support self-management goals.

Support the care team with ongoing panel management activities to ensure timely care, follow-up, and service completion.

Distribute approved patient education materials and resources related to preventive care and chronic disease management, and assist patients in understanding care instructions provided by the care team.

Quality Improvement (QI) and Population Health

Maintain ownership responsibility of assigned patient lists for chronic disease management (especially diabetes and hypertension) and preventive care outreach.

Conduct recurring chart scrubbing to confirm outstanding care needs and ensure accurate identification of care gaps.

Perform direct patient outreach through phone calls, letters, portal messages, and other approved methods to actively close care gaps.

Schedule patients for required appointments, labs, or imaging to ensure completion of recommended care.

Coordinate with patients to address Social Determinants of Health needs by connecting them to appropriate resources, referrals, and support services.

Run population health and compliance reports; reconcile care gap data with payer-provided information to ensure accuracy and completeness.

Track program-specific and patient-level quality measures to develop data-informed intervention approaches that improve clinical and population health outcomes.

Document outreach activities, patient interactions, resource coordination, and gap closure in the EHR following QI workflows.

Collaborate with the QI team to support initiatives that improve clinical outcomes, patient engagement, and operational efficiency.

Participate in trainings, meetings, and performance improvement activities related to quality metrics, population health strategies, and care coordination best practices.

REQUIRED SKILLS AND ABILITIES:

Commitment to improving health outcomes and advancing equitable, patient-centered care.

Ability to maintain strict confidentiality and follow all federal and state privacy regulations, including HIPAA and California privacy laws.

Strong cultural competence, including the ability to recognize and respond to cultural factors that may impact patient engagement and decision-making.

Excellent verbal and written communication skills for interacting with patients, families, and colleagues in person, over the phone, and in documentation.

Demonstrated ability to work both independently and collaboratively within a multidisciplinary healthcare team.

Strong interpersonal skills, with the ability to build constructive working relationships across diverse roles and backgrounds.

Ability to remain calm, fair, and professional when handling difficult or emotionally charged situations.

Strong organizational skills, including the ability to prioritize tasks, meet timelines, and manage multiple responsibilities.

Basic proficiency with computers, including internet use, email, and word processing, with the ability to learn new systems and workflows. Ability to work with spreadsheets and make required data-entries, as relates to outreach tasks.

Experience with Electronic Health Records (EHR) and reporting tools preferred.

Ability to maintain professional boundaries, adhere to ethical standards, and exercise sound judgment in daily responsibilities.

Ability to complete routine paperwork, documentation, and correspondence accurately and professionally.

EDUCATION AND EXPERIENCE:

Medical Assistant experience or certification preferred but not required; training will be provided for all role-specific clinical tasks and workflows.

RRHC is an EOE and offers a 4-day work week, (not all positions will quality for the 4 day work week benefit) and competitive compensation. Health benefits, paid time off and retirement match available for full and part-time employees working over 24+ hours per week. The salary range is $22 to $26 per hour depending on qualifications and experience.

All applications will be carefully reviewed and only qualified candidates will be contacted directly for the next steps.

To start the application process, please submit a resume to: PO Box 769, Redway CA 95560 or complete the application at the top of the page located at https://www.rrhc.org/job-opportunities