High Risk Navigator-Social Services

Description

Summary:

The High-Risk Navigator plays a critical role in strengthening community partnerships to bridge gaps in healthcare, coordinate care, and connect at-risk populations with essential resources. This role focuses on improving outcomes by addressing social determinants of health and referring targeted individuals to appropriate services, including community-based mental health and addiction providers. Acting as a liaison, the High-Risk Navigator coordinates and leverages existing community resources to enhance the quality of care, reduce barriers, and foster patient engagement.

Responsibilities:

1. Convenes coordinated care team meetings that may include representatives from hospitals, local mental health authorities and treatment providers, residential facilities, home care agencies, federally qualified health centers, homeless outreach teams, substance use disorder treatment organizations, social services, health departments, city agencies and housing providers.

2. Identifies individuals in need of intervention. Prepares and delivers case presentations. Develops and oversees community treatment plans for high-risk clients. Serves as a liaison between local hospitals and community based organizations to better coordinate care for complex need individuals.

3. Provides outreach as appropriate for identified high-risk individuals.

4. Facilitates ongoing collaboration among hospital and community service providers to reduce service duplication, optimize resource utilization, enhance care coordination and outreach efforts, connect individuals to providers addressing health-related social needs, and share aggregate outcome data to drive improved outcomes

5. Acts as a representative in local, regional, and statewide committees and meetings to advocate for and advance initiatives that improve care for clients.

6. Establishes policies and protocols to expedite access to services and implements mechanisms that ensure effective follow up.

7. Collects and manages data, including patient reviews, care plans, demographics, and outcomes, to support care coordination and support initiatives.

8. Works with local implementation teams to ensure program goals are being met.

9. Fulfills all compliance responsibilities related to the position. 

10. Maintains and Models Nuvance Health Values.  

11. Demonstrates regular, reliable and predictable attendance.  

12. Performs other duties as required.

Education Skills Experience:

Required: Bachelor's degree. Knowledge of health care field and supportive housing required. Must possess strong leadership skills and strong written and verbal communication skills. Excellent organizational skills are required. Ability to work well with multi-disciplinary service professionals. Good computer skills are required.
Minimum Experience: three years.

Desired: Masters degree in social services, health care, public administration or policy field preferred. A bilingual ability (English/Spanish) is desirable.

Company: Nuvance Health

Org Unit: 2079

Department: Community Health

Exempt: Yes

Salary Range: $29.65 - $55.55 Hourly