Ambulatory Care Navigator Population Health

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Wake Forest Baptist Health
March 11, 2021
Wake Forest, North Carolina
Job Type


Job Description
Job Title:
Ambulatory Care Navigator Population Health
Job ID:
Off Site
Full/Part Time:
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Major Duties


Serves as a liaison between the provider and patient between clinic visits.  Communicates by phone (or in person if needed) when clinical concerns arise and provides transitional care after the patient visits the ED or hospital.  Identifies and addresses barriers to care that might keep the patient from receiving timely and appropriate treatment as well as assists with identifying community resources. Meets weekly with the primary medical team to discuss current patients and identify new patients at risk for services.  Participates in Transitional and Supportive Care rounds to help identify patients who are candidates for services.


Graduation from an accredited School of Nursing.  BSN required with two years' experience as a Registered Nurse.  Case management experience preferred.  Bilingual preference with fluency in Spanish preferred.


Current license as a Registered Nurse (RN) in the State of North Carolina.

Generic Job Description

1.   Responsible for ongoing evaluation and quality improvement of the Navigator Program and tracks all activity as defined by the departmental and program standards.
2.   Ensures quality patient care by adhering to the policies of WFBMC, involving patients and their families in identifying their needs, creating a plan to meet those needs, and effectively communicating the plan across the continuum of care. Identifies barriers to efficient and effective management of patient care and seeks strategies to remove them.
3.   Implements outreach efforts to establish and maintain positive working relationships with key community agencies.
4.   Collects and maintains up to date and accurate program data and documentation according to program standards. Delivers reports that demonstrate outcomes and performance improvement activities; adheres to established productivity benchmarks.
5.   Trained in motivational interviewing and health coaching to provide chronic care management.
6.   Demonstrates ability to function in a professional practice model through active participation in shared governance and acceptance of personal responsibility for professional growth.  Demonstrates responsibility for personal development by participating in continuing education offerings.  Seeks new opportunities for self- improvement.  Seeks and applies constructive feedback to improve performance.
7.   Provides age/developmentally appropriate patient care in accordance with Age-Specific guidelines for the specific age groups served.

Problem solving, decision making and critical thinking skills
Ability to work in a self-directed environment
Ability to work with and lead teams
Demonstrates ability to work in fast-paced environment with multiple interruptions
Expertise in MS Office and ability to prepare program reports frequently and efficiently

Clean, well-lit, comfortable environment
Possible exposure to infections and contagious diseases
Occasional exposure to patient illnesses
Occasionally subject to irregular hours (evenings and weekends)

0% 35% 65%
to to to
35% 65% 100% N/A Activity
X Standing
X Walking
X Sitting
X Bending
X Reaching with arms
X Finger and hand dexterity
X Talking
X Hearing
X Seeing
Lifting, carrying, pushing and or pulling:
X 20 lbs. maximum
X 50 lbs. maximum
X 100 lbs. maximum

How to Apply

To apply for this position, please click on the "Apply Now" button on this page.  You must complete the application process and then submit your application by clicking on the "Submit" button located at the bottom of the page titled "Submit Online Application". You will receive the following message once you hit the submit button: "You have successfully submitted your job application".

Computers are available for applying within the lobby of the Human Resources Department located at 1920 West First Street, (on the corner of Miller and First Street) Winston-Salem, North Carolina  27104. You may also call our office for assistance at (336) 716-6464.  Office hours are Monday-Friday, 8:00am-5:00pm.

If you are an individual with a disability and need reasonable accommodation to participate in the application process, please contact our Supervisor of Office Services by phone (336) 716-3367 or email at

Equal Employment Opportunity

It is the policy of  Wake Forest Baptist Medical Center to administer all educational and employment activities without discrimination because of race, sex, age, religion, national origin, disability, sexual orientation, gender identity or veteran status (except where sex is a bona fide occupational qualification or a statutory requirement) in accordance with all local, state, national laws, executive orders, regulations, and guidelines.

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