Community Health Navigator Lead Panel Support - Pacific Tower (Hybrid, 1.0 FTE)

The Community Health Navigator Lead – Panel Support is responsible for providing community health and social service system navigation to Neighborcare Health patients in assigned populations to reduce barriers to effectively participating in primary care. They achieve this by providing care coordination services for moderate to high-risk patients with identified health-related social needs, including maintaining regular contact with referred patients and assisting them in utilizing appropriate support services. The Community Health Navigator works in partnership and joint accountability with RN Care Management, external Community Health Navigation services, and other internal care team members to achieve Neighborcare’s Mission, Guiding Principles and Goals.

• →Effectively maintain a caseload of empaneled patients in a designated population.
• →Provide high-quality community health navigation support to referred patients in a timely manner. This includes assessing needs, assisting individuals to access and navigate community services, and following up to ensure that services are received. Examples include, but are not limited to:
  • →Housing and emergency shelter placement
  • →Clothing, food and hygiene resources
  • →Medical appointments and specialty referrals
  • →Referrals to community behavioral health resources
  • →Coordinating with other team members for appropriate benefits, e.g. FMLA, DSHS programs, Social Security, Medicare, VA, etc.
  • →Child or Adult Protective Services
  • →Parenting support services
  • →Transportation services
  • →Older adult services
  • →Patient Assistance - DME supply logistics
  • →School IEP services
  • →External Case Managers, Social Workers, or Community Health Workers as needed
• →Collaborate with clinic teams—including RN care management, pediatrics, behavioral health, and support staff—to ensure coordinated care and maximize patient access to navigation services.
• →Assist patients and care teams in documenting screenings, social histories, and navigation activities in the electronic medical record (EHR).
• →Maintain accurate and timely documentation of all care coordination activities.

Family Medicine Panel Support Primary Responsibilities:

• →Carry a rotating panel of patients requiring social services support based on internal referrals or identified needs via screening.
• →Assess clients' needs to develop individualized treatment plans that coordinate care with NCH providers and provide ongoing support and advocacy.
• →Work closely with clients to help them navigate the complexities of health-related social needs and play a key role in helping them achieve their goals.
• →Facilitate collection of further behavioral health and health-related social needs screenings as appropriate and dictated by Neighborcare care guidelines.
• →Refer highest risk and highest complexity patients to Neighborcare RN Care Management or external case managers/social workers as needed in accordance with Neighborcare care guidelines.

CHN Lead Panel Support Primary Responsibilities:

• →Serve as a Subject Matter Expert in community health navigation for specific patient populations.
• →Serve as a Subject Matter Expert in Epic documentation and processes for the community health navigators.
• →Assist in training new team members.
• →Participate in the design, pilot, and implementation of new or optimized workflows.
• →Supports the Community Health Navigation Manager in monitoring progress.

Required for this job:

• Demonstrated ability to work respectfully and effectively with individuals of diverse racial, ethnic, socio-economic, cultural, sexual orientation, and ability backgrounds.
• Ability to communicate clearly and professionally in English, both verbally and in writing, including facilitating conversations and presenting information.
• Strong listening skills and ability to demonstrate tact and patience with patients and colleagues.
• Experience working in a primary care setting, preferably within a community health or Federally Qualified Health Center (FQHC) environment.
• Familiarity with medical and community health terminology, health-related social needs (HRSN), and health insurance, especially Medicaid.
• Working knowledge of electronic health records (EHRs) and practice management systems.
• Basic PC skills in MS Windows environment, 10-key and typing.
• Ability to learn new processes, procedures, and software programs quickly, while demonstrating attention to detail and
  accuracy in their daily work.

Preferred:

• Formal training or certification in community health work, care coordination, or public health.
• Experience with trauma-informed care or motivational interviewing.
• Experience with cross-sector collaboration (e.g. housing, food access, behavioral health).
• Lived experience navigating community health resources or social service systems is strongly valued.

• High School diploma/GED or equivalent relevant experience in a health care or social service setting.
• Must show proof of Community Health Worker Core Competency Course Certificate or obtain within the first 9 months.
• Must show proof of Community Health Worker Pediatric Course Certificate or obtain within the first 12 months of employment.
• Minimum of 1-2 years of community health outreach, patient navigation, health education, or in a role representing or supporting local community agencies.
• Experience working with people of diverse socio-economic and ethnic backgrounds.

• 2-year degree in health, human, or social services related fields, or equivalent relevant experience in a health care or social service setting.
• Bilingual in English and any languages, including those top languages of our patient population such as Spanish, Somali, Amharic, Tigrinya, or Vietnamese.
• 3+ years of social services or community health experience.
• Prior experience in care coordination and patient navigation.

The full job description is available upon request.