Community Health Navigator

Position Available:
Community Health Navigator

Location:

Espanola, NM

Reports To:

Program Manager

Job Status:
Exempt, Full‐time

Benefits:
Health benefits;
Travel stipend; 401K program

Salary: $27/hour to start

The CHN coordinates community and other resources to improve health care delivery for a complex patient population. The position includes significant field time with a variety of direct patient engagement duties including:

• conducting initial intake assessments and risk reduction interventions
• assistance/coordination with access to community resources
• assistance coordinating transportation and housing as needed
• engagement during crisis periods
• resource engagement and allocation
• regular meetings with clients’ care-teams

The CHN works as part of a team under the direction of a Program Manager. The position involves direct interaction with individuals deemed to be high utilizers of community resources to improve their overall care and help mitigate crisis events. The community health navigator will be interacting with patients, primary care providers, medical specialists, social service entities and other community resources to provide an improved care plan for enrolled individuals.

Enrolled individuals have typically been identified as “complex,” and most struggle with issues of homelessness, substance abuse and/or mental health.

This job requires the ability to demonstrate patience and understanding with this high medical and behavioral needs cohort, and the ability to navigate and assist clients with a number of challenging medical and social issues. While most duties will be conducted during pre-determined office hours, there will be requests for off-hours work.

We emphasize the following traits for this position:

• Desire and comfort working directly with at-risk individuals
• Lived experience with issues of homelessness, substance abuse, and/or mental health
• This position does require local travel, and a valid driver’s license is required; access to your own reliable transportation is preferred.
• Basic computer access, intake and filing skills. Ability to access electronic information and participate in virtual meetings via tools such as Zoom.
• Current or ability to obtain Community Health Worker Certification preferred

Preferred skills for the position include, but are not limited to, the following:

• Patient engagement
• Performing intake assessments
• Maintaining frequent patient contact including reminders of appointments; assistance/encouragement to appointments
• Engaging individuals after each emergency department and/or primary care visit
• Assisting clients in finding resources (housing; transportation; food; care)
• Note – Many of the duties will be customized depending on the needs of each individual patient
• Ability to work directly with clients that may be suffering from any number of psycho-social issues including, but not limited to, mental health disorders, substance abuse issues, chronic medical conditions, and homelessness.
• Carry out work duties in a confidential and respectful manner, even when under stress.
• Care Plan creation and maintenance
• Engagement of local/regional Electronic Medical Records in a HIPAA compliant fashion
• Attending local community meetings as needed
• Knowledge of local community challenges preferred
• Engagement of community resources involved in patient’s care; this may include (but is not limited) to resources such as:
• Emergency Department personnel
• Primary Care Providers and Specialists
• Law Enforcement agents
• EMS personnel
• Behavioral Health Centers
• Substance Abuse Treatment Centers
• Therapeutic Courts
• Jails
• On-Call providers
• Housing Authorities
• Other community care coordinators and/or agencies

• Member enrollment into program – this will typically involve phone and direct home and/or field-based contact with members during the enrollment process.
• Create care plans for every enrolled member.
• Assist members in a variety of activities in-home and community-based services, which may include assistance scheduling appointments, assist with travel to/from medical appointments, and engaging providers and community resources as needed.
• Problem-solve…