Social Care Navigator

2 weeks ago

Cornelius, Oregon, United States Virginia Garcia Memorial Health Center Full time
Job Title: Social Care Navigator

Job Summary:

The Social Care Navigator plays a vital role in the Behavioral Health and Medical Home (BHMH) Services Department, working closely with primary care teams to assess and address patients' needs related to their resilience, self-determination, and access to outpatient services and social determinants of health.

Key Responsibilities:

  • Function as an integral part of the BHMH team, attending huddles, team meetings, and coordinating services with team members for complex patients.
  • Assess patients' social determinants of health and health literacy, utilizing screening tools and questionnaires to identify living situations, health literacy, safety, cognitive abilities, and mental health needs.
  • Gather and maintain information on community agencies, local and state organizations, and act as a liaison with outside agencies.
  • Build supportive relationships with patients to improve their utilization of necessary and appropriate primary care, mental health, and social services, leading to improved health status and outcomes.
  • Use motivational interviewing to assess and positively affect patients' engagement in their care and confidence in their ability to carry out a self-management plan.
  • Participate in developing comprehensive care plans with the team.
  • Communicate with the primary care team, documenting all contacts with patients in the Electronic Health Record (EHR) in a timely manner.
  • Provide culturally and clinically appropriate medical and mental health education and information to patients, coaching them in making healthy lifestyle changes.
  • Act as patients' advocates and health navigators, assisting them in understanding the most appropriate use of healthcare resources.
  • Work with primary care teams and BHMH to outreach patients with complex health and/or psychosocial needs and those who are high utilizers of hospital and Emergency Department services, removing barriers to care.
  • Provide work in the community with patients, including home or hospital/ED visits and/or patient accompaniments to medical or social service appointments.
  • May facilitate, coordinate, and organize group education or group provider visits, if approved by the supervisor and in consultation with the site management team.
  • May supervise students in disciplines appropriate to the Navigator's educational background and qualifications.
  • Attend regular trainings as required.
  • Perform other duties as assigned.

Requirements:

  • Bilingual/bicultural proficiency required.
  • Desire to work with underserved communities.
  • Desire to work with complex patients, including those struggling with mental health and/or substance use.
  • Cultural competency.
  • High level of skill in interpersonal relations and problem-solving.
  • High energy and self-directed individual with excellent interpersonal, problem-solving, organizational, and computer skills.
  • Ability to travel to clinics, home visits, and agency visits, etc., in a reliable, confidential, and timely manner.
  • Ability to take initiative to proactively organize and manage the responsibilities of the job.
  • High degree of integrity and professionalism.
  • Good working knowledge of available social service resources or skills to acquire knowledge and information expeditiously.
  • Ability to work in challenging environments in the community at large and in patients' homes.
  • Ability to work as an integral part of a high-functioning team.

Education and Experience:

  • Bachelor's degree in a relevant field or minimum four years of college education, preferably in psychology, social work, human services, or health-related field required, or equivalent combination of education and experience.
  • Meet criteria for QMHA in the state of Oregon (requires a bachelor's degree in behavioral health or alternatively a combination of three years of relevant education and occupational experience).
  • Training in Motivational Interviewing, skills training, and case management preferred.
  • Current CPR certification.
  • Experience with group facilitation.
  • Prior EMR experience preferred.

Behavioral Competencies:

  • Accountability: Role model VG's mission, vision, and shared values.
  • Customer-Focus: Listen to the voice of the customer and strive to delight them by exceeding their expectations.
  • Teamwork: If someone needs help, help them.
  • Initiative: Be innovative, apply fresh ideas, and continuously improve how you do your work.
  • Confidentiality: Maintain strict confidentiality and respect the privacy of others.
  • Ethical: Demonstrate integrity, honesty, and stewardship in all encounters at work.
  • Respect: Demonstrate consideration and appreciation for co-workers and patients.
  • Communication: Demonstrate the ability to convey thoughts and ideas as well as understand the perspective of others.

Physical Requirements:

  • Percentage of time spent: Standing (20%), Walking (25%), Sitting (50%), Reaching (5%), Lifting/Carrying (up to 20 lbs., infrequent 20-40 lbs.).
  • Local travel: up to 75%.

Working Environment/Physical Hazards:

  • Potential exposure to Blood Borne Pathogens.
  • Work environment includes working in patients' homes.

Equipment Used:

  • May use Clinic Vehicles.
  • Computer – data entry and word processing.
  • Telephone, Fax, Copier, Printer, Scanner.
  • Medical equipment: Pulse Oximeter, Glucometer.

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