SDOH Health Population Navigator - QIP

Job Category:
Business Office/Clerical

Requisition Number: PATIE
009140

• Posted:
  July 13, 2026
• Full-Time
• On-site

Showing 1 location

Bergen New Bridge Medical Center is looking for a SDOH Health Population Navigator to provide integrative care and support to diverse community patients.

• Communicates with patient care team members to provide patient with integrative care.
• Carries out tasks to execute the medical and support service plans including guiding patients to appointments and accompanying them when necessary.
• Acts as the primary liaison with medical providers to ensure patient adherence to care.
• Tracks patient attendance for medical appointments, initiates outreach and adheres to missed appointment procedures.
• Coordinates treatment plan adherence.
• Monitors internal data dashboard to coordinate patient care.
• Identifies community resources to address patients' social determinants of health.
• Provides referrals to community resources and follows up to ensure referral completion.
• Maintains program database of community partners and referrals and documentation of all patient encounters, completing reporting requirements per organization and contractual requirements.
• Maintains strict confidentiality in accordance with state and agency policies.
• Attends and represents the organization at professional conferences, in‑service training, and meetings as requested or with supervisor approval.
• Provides flexibility with covering weekend/evening shifts.
• Performs other duties as assigned to support overall objectives of the department and organization.

• Experience as a Community Health Worker, care coordinator, or patient navigator serving complex or vulnerable populations.
• Strong knowledge of SDOH, including housing instability, food insecurity, transportation barriers, benefits access, and other non‑clinical drivers of health.
• Experience with community‑based referrals and resource navigation, including follow‑up to ensure successful connections (closed‑loop referrals).
• Ability to work with high‑utilizers and patients with complex medical, behavioral health, and social needs.
• Familiarity with community‑based organizations, county social services, and benefit systems.
• Strong communication, engagement, and documentation skills, particularly in interdisciplinary care settings.
• Experience in healthcare, social services, or community‑based settings, preferably within a safety‑net or Medicaid‑focused environment.

• Excellent communication and interpersonal skills.
• Experience working with behavioral health and/or substance use population.
• Experience in a medical or social services environment preferred.
• Strong attention to detail.
• Proficient with computer databases.
• Analytical problem‑solving skills.
• Ability to manage time, prioritize, and meet deadlines.
• Ability to work independently and as a team member.
• Proficiency in Spanish preferred.

Bachelor's Degree in behavioral health field required;
Master's Degree in behavioral health field preferred.

Salary: $47,000-$60,000 per year.

Comprehensive benefits package including medical, dental, vision plans. Work‑life balance with generous time off, including vacation days, personal time, sick leave, and nine paid holidays. Tuition reimbursement and continuing education programs available.

Equal Opportunity Employer. This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.