Community Navigator - St. Rita's Medical Center

At Bon Secours Mercy Health, we are dedicated to continually improving health care quality, safety and cost effectiveness. Our hospitals, care sites and clinicians are recognized for clinical and operational excellence.

The Community Navigator supports Mercy Health Lima clinics by providing comprehensive, community-based navigation and coordination services that address the social determinants of health (SDOH), improve care coordination, and enhance access to health system and community resources for underserved and vulnerable populations. This role works collaboratively across multiple care settings, including mobile and community clinics, primary care practices, and community partner sites.

The Community Navigator collaborates with physicians, clinic staff, community organizations, and other stakeholders to deliver holistic, patient-centered care. This position requires a self-directed professional who can work across clinical and community environments, manage competing priorities, support care transitions, and contribute to program development, data tracking, and continuous improvement efforts aligned with organizational mission and grant deliverables.

• Conduct standardized social determinants of health (SDOH) screenings with patients served through the mobile clinic and community-based clinics
• Provide individualized care navigation, including assessment of social, financial, behavioral health, housing, food, transportation, insurance, and utility needs
• Assist patients with applications, referrals, appointment scheduling, and follow-up for community and health system services
• Support uninsured or underinsured patients with insurance enrollment assistance and linkage to primary care
• Provide brief education and counseling related to identified social needs and available resources

• Collaborate with resident physicians, attending providers, and clinic staff to support continuity of care and reduce fragmentation
• Facilitate referrals to primary care, specialty care, behavioral health, and community services
• Support transitions of care between mobile clinic visits, resident clinic care, and community partners
• Participate in interdisciplinary team meetings and contribute to patient-centered care planning

• Build and maintain relationships with community-based organizations addressing food insecurity, housing, transportation, employment, and behavioral health
• Represent Mercy Health at community events, mobile clinic sites, and partner locations as appropriate
• Coordinate with partners such as food banks, community centers, faith-based organizations, and free clinics to strengthen referral pathways
• Serve as a trusted liaison between patients, clinics, and community resources

• Document patient encounters, SDOH screenings, referrals, and follow-up activities in approved tracking systems and/or the electronic health record
• Track referral outcomes and successful connections to services in alignment with grant objectives
• Assist with data collection and reporting related to grant deliverables, outcomes, and performance measures
• Participate in quality improvement efforts to enhance screening rates, referral success, and patient engagement

• Support the development and refinement of SDOH workflows within mobile and clinic-based care settings
• Provide patient education related to community resources, insurance, chronic disease management, and health access
• Assist with training resident physicians and clinic staff on SDOH awareness, referral processes, and community resources
• Contribute to program sustainability planning through documentation of outcomes and lessons learned

Education: A Baccalaureate degree in social work, psychology, sociology, or other field related to social work services.

• A bachelor’s degree in social work, psychology, sociology, public health, human services, or a closely related field.
• Strong communication, documentation, and…