Community Health Navigator

2 days ago

Richmond Virginia, United States HarmonyCares Full time
About the Role

As a Community Health Coordinator at HarmonyCares, you will play a vital role in implementing a person-centered plan of care to assist patients and their families navigate access to community services and resources.

Key Responsibilities
  • Assist patients in identifying and navigating to and through various health and social resources that will help patients achieve health outcomes.
  • Work as part of a collaborative care team to achieve optimal quality and patient experience outcomes, including being an active member in patient High Risk Huddles.
  • Provide home visits when necessary to at-risk patients and families for evaluation of needs to provide assistance.
  • Reach out to patients who are discharged from the hospital and/or Emergency Room in order to understand, collect, and close care gaps.
  • Report specific health and social information as part of the interdisciplinary care team.
  • Address identified barriers to care that led patients to the utilization of ED rather than their HarmonyCares Medical Group provider.
  • Encourages high risk patients or utilizers to engage with their HCMG provider before utilizing the acute care setting.
  • Perform a variety of assessments with patients they engage with, to include, but not limited to, Social Determinants of Health.
  • Document all activities in various systems.
  • Perform other duties as assigned.
Requirements
  • High School Diploma or equivalent.
  • Experience working with community agencies providing services encompassing the basic competency areas of health care (community resources, communication skills, individual and family advocacy).
  • Familiarity with the resources available within the community.
  • Self-directed with excellent problem solving skills.
  • Must be well-organized, detail-oriented, and have the ability to multi-task in a demanding and constantly changing environment.
  • Strong interpersonal communication skills and the ability to communicate easily with others, including demonstrating active listening skills.
  • An ability to gain respect and build rapport with community members.
  • Demonstrate flexibility in addressing changing community needs and program environment.
  • Ability to travel within assigned geographic area if required by leadership.
  • Valid driver's license and automobile insurance required.
  • Strong time management skills.
  • Strong commitment to patient advocacy.

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