Patient Navigator - 3063

Job Summary

The role of Patient Navigator may sometime be referred to as the Status Neutral Navigator (SNN). This role plays a central role in supporting our integrated syndemic services-encompassing HIV, PrEP, HCV, and drug user health- SNN operates using a status-neutral, stigma-free approach, meeting each member exactly where they are, regardless of diagnosis, and supporting them on both treatment and prevention pathways.

As the engagement engine for our program, the SNN leads efforts around linkage, engagement, and retention across the entire continuum of care. The SNN also ensures seamless coordination between local initiatives and our shared services resources.

A key aspect of this role involves community outreach and partnership development. The SNN collaborates with community-based organizations, public health agencies, and local stakeholders to broaden access to care and encourage engagement. Serving as the in-market point of contact for all external partners.

The Patient Navigator will be the in-market point of contact for all external partners to coordinate rapid, red-carpet linkage to care and treatment initiation services, including care and treatment initiation for individuals newly diagnosed or re-engaging with care, PrEP and PEP linkage, and other viral hepatitis and harm reduction services.

In addition to providing linkage to care services, the Patient Navigator will maintain a caseload of high-priority members for retention support across the Center's syndemic services. In this role, the Patient Navigator will work collaboratively with PCP teams and members to address and resolve barriers to care.

This position will work in a fast-paced environment requiring exceptional organizational and interpersonal skills, this individual must non-judgmental and able to meet clients where they are at in the care process.

The work may involve travel to community-based organizations and clinics to assist in status-neutral linkage to care services  ideal candidate will be well versed in providing culturally competent and affirming care to individuals with diverse experiences through a harm reduction lens.

Duties and Responsibilities

• Provide in-person and virtual navigation, follow-up, and support to members newly diagnosed with HIV, re-engaging in care, and those accessing prevention services within Absolute Care
• Deliver status-neutral navigation across prevention and treatment pathways
  , including HIV care, PrEP/PEP, viral hepatitis, and harm reduction services
• Ensure timely linkage to care and ongoing retention support
  , maintaining a caseload of high-priority members
• Conduct comprehensive barrier assessments and address social determinants of health, including:
  • Housing instability
  • Insurance access
  • Transportation
  • Intimate partner violence
  • Behavioral health and substance use needs
• Support members in accessing and navigating:
  • Ryan White services and community-based resources
  • Insurance coverage options (Medicaid, ADAP/LA-HAP, and other access programs)
• Assist members in identifying and resolving insurance and medication access barriers
  , including support for HIV treatment and PrEP
• Provide member education and coaching
  , including:
  • Self-advocacy and health literacy
  • Medication adherence and prevention strategies
  • Effective communication with healthcare teams
• Build trusting, culturally competent relationships to support engagement in a complex healthcare system
• Partner with providers, pharmacy, and multidisciplinary care teams to:
  • Support medication and lab adherence
  • Schedule and coordinate appointments
  • Address disengagement and care gaps
  • Ensure continuity of care
• Serve as a liaison between members, social workers, clinic staff, and care teams to ensure coordinated, person-centered care
• Communicate member risks or concerns (e.g., non-adherence, substance use, disengagement) to the care team in a timely manner
• Conduct routine follow-up and outreach to promote sustained engagement and retention in care
• Maintain accurate, timely documentation of all services, outreach, and care coordination activities in the EMR
• Ensure strict confidentiality of all member information

• Partner with the Senior Manager of HIV/ local market leadership to implement and execute syndemic and status-neutral programming aligned with organizational strategy
• Coordinate and manage walk-in and urgent linkage services
  , including:
  • Members presenting for HIV testing, counseling, and linkage
  • Referrals generated through outreach and community engagement
  • Development and documentation of follow-up plans for interdisciplinary review
• Attend and actively contribute to Population Health meetings, team meetings, and daily huddles
• Monitor and manage:
  • EMR reports, dashboards, and work queues
  • In-basket messaging from team members
  • Non-clinical coordination needs impacting member care
• Support development and refinement of linkage-to-care protocols and workflows
  , adapting to local market needs and resources