Pathways Care Navigator

Our Vision

As the premier provider of substance use and mental health services in the Pacific Northwest, we are respected and the most trusted resource for behavioral health treatment and whole person care. We provide a comprehensive continuum of coordinated quality services, foster enduring relationships, and empower our communities to truly thrive.

Our Mission

Through superior customer service, high quality programs, and a well-trained and dedicated staff, we inspire hope and support lifesaving changes for people affected by substance use and mental health conditions.

Salary: $19.50-$22.50 per Hour

MAJOR DUTIES: This position provides care coordination to agency patients or persons requesting services. Care Navigators are designed to utilize the Pathways model to provide support to patients. Care Navigators work one-on-one with patients to help them better self-manage their health through coordination with their providers and education on local resources. In fulfilling these duties, the incumbent performs the following duties independently:

1. Provide outreach and initial Community Needs Assessments resulting in the development of a client profile and initial checklist.
2. Additional health screens can include the Patient Activation or Caregiver Activation Measure (PAM/CAM), Patient Health Questionnaire (PHQ-9) and the KATZ measure for activities of daily living. Other screens may be used as appropriate for care. The patient checklist will be updated at every visit;
3. Supporting the patient in attaining short and long term goals. Motivational interviewing techniques will support goal setting. The CN will spend time advocating, educating and supporting the patient and natural family supports to attain and improved self-management skills;
4. Provide cultural mediation between communities and the healthcare service system, culturally appropriate and accessible health education and information, informal education, counseling and social support and advocacy for individual and community needs;
5. CNs are a part of and familiar with the communities they live and work with; they are comfortable working in team environments, while building trust with their community members, local service organizations and healthcare providers to build individual and community capacity;
6. As a routine part of working with the Pathways model, the CN, led by the community member, will assess needs and establish a series of Pathways, often requiring referrals to partner organizations that specialize in providing specific health or social services. An essential part of the CN role is to establish solid relationships with key staff people throughout their entire referral network of organizations in order to ensure their ability to follow up on the community members’ status once referred to an external or internal referral partner;
7. The CN, in consult with contact person(s) from referral partner organizations, will use the CNS HUB Connect software to track the number of referrals, both internally and to other external organizations, and assure that the referrals are completed by using Pathways;
8. CN will meet ongoing both in person and telephonically to support patient and the patient attainment of health care goals. Required to complete minimum of one (1) home visit or community visit with participants, every 30 days, considerate to agency’s physical distancing guidelines;
9. Coordinate with the authorizing and health care or social service entities as necessary to maintain self-care and support the patient’s goals;
10. Focus on several key indicators of health, both medical and social, called pathways. Care Navigators support patients in working through specific pathways to ultimately improve their health outcomes;
11. Care Navigators will document patient progress and recommendations in the Pathways care coordination system. All in person and telephonic encounters will also be documented;
12. Attend HealthConnect monthly meetings and required trainings;
13. Utilize HealthConnect / HUB Connect Software to track referrals;
14. Carry a caseload (As an example, a full-time CHW/Peer could carry a caseload of 40-60 moderate risk community members, or 25 very high-risk individuals). Exact caseload size will be fluid, based on duties assigned and acuity of persons’ served in consultation with Program Director; and
15. Other duties as assigned.

KNOWLEDGE AND SKILLS REQUIRED BY THE POSITION

1. Possess a high school diploma or equivalent and 2 years of experience working in a related field/profession;
2. Associates or Bachelor's degree in a related social service field preferred but not required;
3. Above average Microsoft Office skill set;
4. Experience working within health systems or providing case management;
5. Experience with underserved, transient populations;
6. Unencumbered driver’s license and the ability to become an approved driver per agency policy;
7. Familiarly in Motivational Interviewing techniques; and
8. Strong communications skills.

GUIDELINES

Requires that the incumbent relies on specialized training and/or equivalent experience and performs duties in accordance with Washington Administrative Codes, Federal regulations governing the confidentiality of patient files, and Lifeline Connections Policy and Procedure Manual.

PERSONAL CONTACTS

Contacts are with the members of the treatment team, patients, significant others of the patients, representatives of various community agencies specializing in the treatment of substance use and mental illness, and related community representatives including hospital personnel, lawyers, probation officers, and other court officials. All personal contacts are carried out in accordance with federal and state laws dealing with the confidentiality of patient records.

PHYSICAL DEMANDS

While performing the essential functions of the job, the employee is regularly required to sit, speak clearly, hear, and use hands and fingers to manipulate writing utensils and keys on a keyboard. The employee is occasionally required to stand, walk, reach with hands or arms, stoop, kneel, crouch, or lift and/or move maximum of 15 lbs.