Community Resource Navigator

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Reports to the designated Manager (Population Health Care Coordination). Functions as a member of the care coordination team with a primary focus on direct intervention services with individuals and families served by Population Health Care Coordination. Assists patients to receive the services and ambulatory care they need with the goal of managing chronic health conditions. Serves as a link to community-based social and healthcare services, including primary and specialty care as well as community-based organizations and works as an advocate for clients as they navigate these systems.

Provides informal coaching, health education and self‑management instruction—liaisons between Beacon Care Coordination and community providers.

Mission, Values and Service Goals

• MISSION:
  We deliver outstanding care, inspire health, and connect with heart.
• VALUES:
  Trust. Respect. Integrity. Compassion.
• SERVICE GOALS:
  Personally connect. Keep everyone informed. Be on their team.

Identifies and Enrolls Individuals Who Are in Need of Healthcare Services

• Working with Beacon Care Coordination to find patients who are facing significant social barriers to managing their health and well‑being.
• Employing creative strategies, with approval, to capture other patients in identified population who require social care assistance.
• Becoming visible and active within the health care system; forming tight working relationships with Population Health team and community providers.
• Scheduling appointments for patients with providers. Providing education and coordination to ensure follow through.

Assists in the Client's Care Coordination

• Completing intakes, assessments and Care Plans in collaboration with the Care Coordinator. Assessing and addressing any social/practical barriers patients may face to follow through with care.
• Providing support to patients to achieve their goals; assisting clients to navigate available community resources and healthcare services.
• As appropriate and safe, visiting clients/patients in their homes or other community locations to provide support, encouragement and guidance.
• Acting as an advocate for families and making referrals to other appropriate community agencies to meet the needs of the family.
• Providing individualized educational and emotional support in accordance with the intervention plan.
• Helping clients/patients improve their health risk behaviors.
• Helping clients identify a personal support system.

Supports the Care Coordination, Population Health Department

• Maintaining records, reports and files as required by departmental procedures; also keeping accurate records of home visits, appointments and referrals.
• Following up with clients who have missed an appointment.
• Meeting with the Care Coordination Team, on a regular basis, to review individualized care plans, share information and report progress.
• Providing basic health education for clients and their families.
• Communicating with the Manager regarding any concerns or problems.
• Participating in orientation and training sessions.
• Obtaining and evaluating impact and social need data for strategic planning purposes.
• Building relationships with community providers to improve collaboration and finding additional resources.

Performs Other Functions

• Completing other job‑related duties and projects as assigned.

Organizational Responsibilities

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established time frames.
• Completes annual employee health requirements within established time frames.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department…