Community Care Navigator - Asheville, NC

JOB SUMMARY

Care Navigation will be part of MAHEC’s Population Health Administration embedded in primary care teams to ensure that patients receive the resources and services they need. The Care Navigator positions work with the clinical teams, behavioral health and community providers, to coordinate care and meet performance goals. The role’s primary responsibility is assisting patients with needed support services to achieve personal goals and optimal health.

Engages and interacts with patients and/or family members to obtain and document accurate histories, builds a trusting relationship, and implements a person-centered care plan. Works to develop a strong relationship with identified patients and facilitates patient engagement during in person visits, group visits and virtually. Uses motivational interviewing to gather pertinent clinical and psychosocial information from the patient and his/her friends and family as appropriate and coaching and support to achieve self-management goals.

Proactively identifies potential barriers to care plan, initiate interventions with Providers(s), Nursing care managers, clinical social workers, and other caregivers to include alternative options to meet desired goals. Communicates effectively with appropriate caregivers to achieve targeted outcomes. Documents activities, service plans, and results in an effective manner with EHR and care management platform Refers patients and their families, who need assistance, to the appropriate educational resources regarding health care delivery and reimbursement, prescription drug programs, health and wellness programs, long term care insurance, asset and legal management, government programs, community agencies, public and private organizations, housing options, and other services, as appropriate.

Provides patient self-management support for priority chronic conditions or pregnancy and well childcare. Collaborates with practice and organizational leadership to define workflows that meet contracted goals and requirements for screening, quality, outreach and care coordination to meet the goals of contracted requirements. Utilizes a “Team Based Care” approach to ensure patients are appropriately screened for depression and social determinants of health.

Supports follow up on positive screening. Uses documentation tools to support the patient goals, documentation of the care plan and closed loop referrals for health-related social needs. Utilizes available tools to identify clinical gaps in care and communicate with the clinical team to support closing quality gaps and evaluate suspect conditions. Ensures communication of the patient care coordination plan to members of the Primary Care team.

Serves as a liaison between care teams and community groups and foster and develop relationships with key contacts in those groups. Collaborates with leadership to maintain partnerships with local community-based agencies and programs and support the success of the team in navigating these patient care needs. Works with leadership to provide training on the workflows and documentation of health related social need to assure a plan for success in using the system to accept and respond to referrals.

Supports obtaining and developing education for clinical team to understand community partners in the counties served. Supports Clinical Providers, Care Managers and Behavioral Health Consultants in coordinating community providers/services. Utilizes a “team-based approach” to manage and assist in the care coordination process. Seeks to eliminate confusion and duplication in services and supports quality, value- oriented care in coordination with patients, caregivers, providers, and appropriate community care partners.

Collaborates to maintain a resource database specific to patient’s local needs.

Communication Skills Effectively and respectably communicate with other individuals, whether it be a colleague, patient, or patient’s family member and appropriately enumerate information in a manner easily understood by all parties. We do this to foster a culture of understanding between all parties,…