Care Navigator

ESSENTIAL JOB FUNCTIONS:  Essential functions of the job include, but are not limited to, traveling, driving, utilizing a computer for typing and conducting research, attending meetings, conducting assessments, and counseling.

MAJOR AREAS OF RESPONSIBILITIES:

• Promotes and reinforces patient centered medical home concepts with patients, families, and the Equitas Health care team.


• Participate in the development and implementation of an evidence based, standard screening tool for identifying patient’s social determinants of health. The care navigators will utilize this tool to determine factors that contribute to a patient’s overall health outcomes, and develop the appropriate intervention/care plan for the patient.


• Assist patients in accessing Equitas Health resources and navigating external healthcare and community resources such as housing, respite, nutritional assistance, palliative care, chore assistance, transformation and social functions; taking into consideration reading level, health literacy, culture, and language requirements. Assess barriers to care and engage patients and families in creating potential solutions to overcoming these barriers through the use of motivational interviewing and shared decisions making.


• Refer to community workforce programs and provide supportive services to patients that address the unique barriers to employment individuals may face in returning to work, understanding benefits eligibility, confidentiality and health management in the workplace.


• Collaborates with providers, client services, and care team to develop short and long term strategies in the development of expected patient outcomes as they impact the patient’s physical health, mental health, and ability to function within their day to day environment; collects data through patient tracking to meet patient’s needs.


• Works collaboratively with providers and care team to ensure the delivery of quality of care to patient to ensure the best patient outcome.


• Collects data through patient tracking in order to facilitate patient outcomes data collection and analysis.


• Provide assistance with completing and submitting all necessary documentation related to patient’s care, including documents related to Ryan White benefit, health insurance, medical procedures, and internal and external referral services.


• Serves as a link between Equitas Health Medical Center and Client Services, ensuring patient’s needs are being met with timeliness and efficiency.


• Maintain confidentiality of patients by adhering to Equitas Health Confidentiality Policy and Procedure, HIPAA, and other established professional standards and guidelines.


• Care Navigators are responsible to maintain documentation through Equitas Health, ODH, and other software systems. All documentation will demonstrate best practices and will reflect patient centered and affirming care. All documentation will be recorded and complete within one business days of provided service.


• Effective written and verbal communication skills. Ensure that action items and updates are provided to Supervisor proactively.  Capture feedback from patients, families, Equitas Health care team, and community partners and communicate the information to the appropriate persons.


• Returns patient, provider, and other stakeholder correspondence within two business days.


• Responsible for accurate and timely completion of documentation in order to provide accurate data and reports to Equitas Health and its Board, as well as federal, state, and local governments.


• Attend trainings, as assigned, to support professional development and best practices and to maintain standards for licensure.


• Care Navigators will participate in Motivational Interviewing trainings and Learning Groups. As appropriate, Supervisors will schedule shadowing and review recorded visits between staff and patients in order to evaluate Motivational Interviewing skills.


• Participate in Equitas Health Committees and Performance Improvement Teams as appropriate and as assigned by supervisor.


• Demonstrates unconditional positive regard to patients; Conducts all aspects of job responsibilities with a focus on exceptional customer service.


• Demonstrates continuous growth and development of Cultural Competency exhibiting an understanding, awareness, and respect for diversity.


• Attend monthly, quarterly, and as needed meetings in-person at multiple agency sites and community partner locations.


• Utilize email, teams, phone, and other telecommunication options to participate in meetings across sites.


• Other duties as assigned related to this position by supervisor.

EDUCATION/LICENSURE:

• Education Requirements: Bachelor’s Degree in Science, Social Work or related field.


• Licensure Requirements: Minimum LSW

Knowledge, Skills, Abilities and other Qualifications:

• Must have sensitivity to, interest in and competence in cultural differences, HIV/AIDS, minority health, sexual practices, and a demonstrated competence in working with persons of color, and gay/lesbian/bisexual/transgender community.


• Medical and Community-based care navigation training experience desired.


• Understanding of NCQA Patient Centered Medical Home, Comprehensive Primary Care Initiative, Accountable Care Organization, or other value based care delivery model preferred.


• Experience working in a multidisciplinary team required


• Proficiency in all Microsoft Office applications and other computer applications required.


• Reliable transportation, driver’s license and proof of auto insurance required.