Community Resource Navigator

1 month ago

Harwich Port, United States Outer Cape Health Services Full time
Job DescriptionJob Description

Our Culture: Why work with us?

Joining Outer Cape Health Services isn't just about taking on a new role; it's about embracing a mission that goes beyond the day-to-day. Here, you become part of a dedicated team committed to safeguarding and nurturing invaluable community health resources. Our ethos is built on creating a vibrant and inclusive workplace where every team member is valued and recognized for their unique contributions.

Who We Are :

Our mission is to provide a full range of primary health care and supportive social services that promote the health and well-being of all who live in or visit the ten outermost towns of Cape Cod.

OCHS now cares for more than 18,000 patients annually, and no one is denied access to services due to an inability to pay. Founded in 1987 through the merger of Health Associates of Provincetown (established in 1972) and the AIM Medical Center in Wellfleet (established in 1966), Outer Cape Health has a long history of successful growth and expansion in pursuit of this mission. As a Patient-Centered Medical Home, OCHS holds itself to the highest standards. Ensuring patients have access to care when they need it and request it, and validating that staff are working at the top of their licensures, are foundations of this model.

Our Core Competencies:

At Outer Cape Health Services, our core competencies are the foundation upon which our organization is built, guiding us in our mission to deliver exceptional health services to our communities. Our focus on fostering teamwork ensures that we operate as a cohesive unit, valuing each member's contribution and working synergistically towards common goals. Integrity and honesty stand at the heart of everything we do, creating a culture of trust and respect among our team and the communities we serve. Embracing technology, we continually seek innovative solutions to enhance our services and operations. Finally, being patient-centered, we prioritize the needs and well-being of those we serve, striving to exceed expectations and make a meaningful difference in their lives.

A day in the life of this role:

The Community Resource Navigator will work closely with community partners to identify potential clients, conduct and assist with needs assessment, collect and record required data, provide client case management, connect clients with services and treatment, and develop a client-centered service plan.

Summary of duties:

  • Identify at-risk individuals, contact them, explain program benefits/risks, enroll interested and eligible participants, collect required data, and deliver services.
  • Regularly meet with representatives from across a broad spectrum of partnering community partnering agencies such as human services, health care providers, law enforcement, hospital emergency department, courts, emergency medical teams, social services, housing agencies etc. to forge and sustain durable relationships.
  • Assist in coordinating the community's human services and related resources on participant's behalf.
  • Establish contact, build and maintain effective relationships with identified clients.
  • Assess each client's history and needs using assigned screening/assessment tools.
  • Stay connected with clients on a need- and resource-appropriate basis to ensure adherence to service plan.
  • Track patient progress through contact and ongoing reassessment, collecting and inputting all required data into the required systems (e.g., Epic and Arcadia).
  • In cooperation with client, OCHS clinicians, and community representatives, develop a treatment plan to engage clients with an appropriate range of service and treatment options.
  • Facilitate clients' navigation and utilization of wrap-around support and healthcare services.
  • Facilitate and coordinate follow-up case conferences with referring agencies.
  • Coordinate referrals to community substance abuse services, and mental health services as necessary.
  • Collect and enter all Community Resource Navigator Program data to support assessments, tracking, patient registry, chart reviews, and patient satisfaction surveys.
  • Actively participate in CRN program, behavioral health, departmental and general staff meetings and/or agency committees as required.
  • As assigned, interact with referring resources such as Emergency Department inpatient behavioral health/substance use navigators from Cape Cod Hospital and other referring organizations to rapidly facilitate coordination and transition to OCHS programs such as OBOT, Healthy Connections or Care Coordination.
  • Adhere to established case management standards of care.
  • Adhere to OCHS policies and practices.
  • Other duties and projects as assigned to meet the expectations of the position.

Work environment:

  • Travel to all three sites.

What we need from you:

  • High school degree, or the equivalent
  • Valid Massachusetts driver's license (or ability to obtain)

AAP/EEO Statement Outer Cape Health Services is committed to a firm policy in favor of equal employment opportunity and will abide by all applicable state and federal regulations by not discriminating against any applicant or employee on the basis of race, religion, color, creed, sex, age, national origin, citizenship status, marital status, sexual orientation, gender identity and expression, disability or veteran status. Our commitment to equal employment opportunities shall include employment, upgrading, promotion, demotion, transfer, leaves or other absences from work, layoff, compensation and benefits, selection for training or other education, professional opportunities and conflict resolution.

It is also the policy of OCHS to take affirmative action to employ and to advance in employment, all persons regardless of their status as woman, minority or individuals with disabilities or protected veterans, and to base all employment decisions only on valid job requirements.

Please inform us of any necessary accommodations required during the application process and/or at any time during employment.



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