Community Health Navigator
4 weeks ago
MedZed Group is seeking a highly motivated and compassionate Community Health Navigator to join our team in Marin County. As a Community Health Navigator, you will play a critical role in delivering patient-centered care and support to our members enrolled in our Enhanced Care Management (ECM) program.
Job Summary:The Community Health Navigator will work closely with our members, caregivers, and healthcare providers to identify and address the complex medical, social, and psychosocial needs of our members. This role requires a strong understanding of patient-centered care, care planning, and case management, as well as the ability to build and maintain relationships with community agencies and healthcare providers.
Responsibilities:- Manage caseloads of referred, assigned, and enrolled members with complex medical, social, and psychosocial needs.
- Communicate effectively with members, caregivers, and/or families to cultivate professional, supportive relationships.
- Understand social/complex case management and participate in clinical rounds, case consultations, and team huddles.
- Empower members and families to overcome barriers and improve health outcomes.
- Complete member assessments, including safety/risk assessments, health needs assessments, and psychosocial needs assessments.
- Develop and create unique care plans for members, caregivers, and/or families to support identified needs.
- Assist members with service coordination, including scheduling appointments, booking transportation, and assisting with referrals/authorizations.
- Consult and collaborate with other healthcare team members, hospitals, provider offices, service/delivery agencies, community agencies, and/or social service programs.
- Provide discharge planning support and post-discharge support as appropriate, including collaboration with inpatient hospital teams and/or providers.
- Manage ongoing follow-up with members/families via phone calls, home visits, and community setting visits to ensure members are achieving healthcare goals and receiving appropriate resources.
- Maintain professional, accurate, and quality records by documenting them in a timely manner into our care management system.
- Proven understanding of patient-centered care.
- Proven experience with care planning, case management, and managing caseloads.
- Proven experience working with vulnerable and culturally diverse populations.
- Knowledge of community resources within the community of the member being served.
- Ability to maintain clear and professional boundaries with members and coworkers.
- Have a basic understanding of different therapeutic services, including physical therapy, occupational therapy, speech therapy, and applied behavioral analysis therapy.
- Knowledge of the process for referrals and authorizations in federal, state, local, and community-based organizations.
- Ability to quickly establish and maintain rapport and trust with members.
- Ability to problem-solve, critically think, and collaborate effectively.
- Experience with clinical rounding and collaboration with multidisciplinary teams.
- Ability to identify mental health concerns, substance use concerns, medical issues, need for durable medical equipment, and/or other needs.
- Experience working with child, youth, and families (if hired to work with the pediatric population).
- For pediatric populations, knowledge of IEPs, 504 plans, Regional Centers, Wrap-around programs, Child Welfare/Foster Care, School-based programs, etc.
- Must be able to thrive in a fast-paced environment that is constantly evolving with new requirements and innovative program delivery techniques.
- Ability to follow HIPAA standards in safeguarding patient information.
- Able to work with Microsoft Office, Excel, and Outlook (email).
- Have a valid driver's license.
- Access to an insured and reliable car.
- Bachelor's degree (social work, psychology, sociology, or public health a plus).
- Master's degree a plus (MSW).
- Minimum of 2 years' experience working in medical, mental health, social, or community services required.
- Minimum of 1 year's experience with ages 0-21 years of age (if hired to work with the pediatric population).
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