Community Health Navigator - Fresno, Ca.

Community Health Navigator

Summary

The Community Health Navigators (CHN) for our Enhanced Care Management (ECM) Program is the front-line field team member that works to impact the Population of Focus in their market. This position is passionate about the MedZed mission and embodies the STRIVE values daily. This individual is focused on delivering whole personal care to each member enrolled into the ECM program. This is a remote-field worker who is primarily out in the community coordinating services with members, providers, and community agencies to improve member care, outcomes and works with special populations, who may be homeless, may have serious mental illness or substance use disorders, or may need services to prevent such conditions.

In addition, the candidate possesses strong interpersonal skills with the ability to build and maintain team and community relationships. The successful candidate will report to the Program Manager.

Daily Responsibilities

• Manages caseloads of assigned enrolled members with complex medical, mental health, and psychosocial needs.

• Communicates effectively with members and/or families in person and remotely to cultivate professional member/ care manager relationship.

• Understanding medical/complex case management and social work skills and participating in clinical rounds, case consultations, and team hurdles.

• Promoting self-determination and empowering members and families to overcome barriers and improve health outcomes.

• Serving vulnerable populations such as homeless, severe mental illnesses, substance use disorders, addiction, medically underserved, at risk children/youth, disabled, chronic illnesses, high utilizers of emergency services, etc.

• Completing member assessments including, but not limited to safety/risk assessments, health needs assessments, psychosocial needs assessments.

• Developing and creating unique care plans for members and/or families to support identified needs.

• Documenting member and family information, diagnosis/medical insight, treatment plan, goals, interventions, evaluation/assessment information, observations, and overall progress during ECM program.

• Assisting members with service coordination such as scheduling appointments, booking transportation, assisting with referrals/authorizations.

• Advocates for members and/or family to ensure health and safety needs are addressed and appropriate resources are being provided.

• Linking members and families to appropriate community resources for financial assistance, transportation, clothing, support groups, food, housing/shelters, sobering centers, etc.

• Consulting and collaborating with other healthcare team members, hospitals, provider offices, service/delivery agencies, community agencies, social service programs and/or agencies etc.

• Providing support to members in the hospital, discharge planning support, and post discharge support as appropriate including collaboration with inpatient teams and/or providers.

• Accompanying members to health appointments if needed, no transportation of members required.

• Ongoing follow up with members/families via phone calls, home visits, and community setting visits to ensure members are achieving health care goals and receiving appropriate resources.

• Maintain professional, accurate and quality records. Placing documentation in a timely manner into health record.

• Knowledge of community resources, services, programs, and agencies that will support members and their families and the ability to build strong relationships with these organizations.

• Other duties as assigned.

Qualifications

Job Qualifications

• Must understand patient centered care and whole person care models.

• Must have experience with care planning and managing caseloads.

• Must have experience working with vulnerable populations (homeless, high utilizers, at risk child/youth, severe mental illness, chronic conditions, etc.)

• Must have an ability to work with a diverse population, cultural competency.

• Knowledge of community resources within the community of the member being served.

• Able to maintain clear and professional boundaries with members and coworkers.

• Understanding of case management and medical case management services

• Have a basic understanding of different therapeutic services including but not limited to physical therapy, occupational therapy, speech therapy, applied behavioral analysis therapy, etc.

• Working knowledge of social, mental health, and medical issues

• Knowledge of process for referrals and authorizations

• Ability to quickly establish and maintain rapport and trust with members.

• Ability to manage complex caseload and provide quality care to all members.

• Ability to problem solve, think critically, and collaborate effectively.

• Must have training and experience with community health, Maslow's hierarchy of needs, social determinants of health, identifying strengths and barriers, and stages of readiness.

• Experience with clinical rounding and collaboration with multidisciplinary team.

• Training and experience in completing psychosocial, health needs, and safety/risk assessments.

• Training and experience with providing brief solution focused therapies, crisis intervention, problem solving techniques, harm reduction interventions, and motivational interviewing.

• Ability to identify mental health concerns, substance use concerns, medical issues, need for durable medical equipment and/or other needs.

• Must have knowledge of community-based healthcare and social service systems and have a basic understanding of programs available to underserved populations and older adults/seniors.

• Understanding state programs including, but not limited to Medicaid, In Home Supportive Services (IHSS), SSI/SSDI, CalWorks, etc.

• Experience with child, youth, and families (if hired to work with the pediatric population)

• For Pediatric Populations, Knowledgeable about IEPs, 504 plans, Regional Centers, Wrap around programs, Child Welfare/Foster Care, School-based programs, etc.

• Must have strong organizational skills and excellent oral and written communication skills.

• Strong interpersonal and social skills with demonstrated ability to collaborate with a variety of individuals from a wide range of professional and personal backgrounds.

• Must be able to prioritize and follow guidelines/meet deadlines.

• Must be able to thrive in a fast-paced environment that is constantly evolving with new requirements.

• Follow HIPAA standards in safeguarding patient information.

• Able to work with Microsoft Office, Excel, and Outlook (email

• Represent the company with professionalism.

• Knowledge of reporting mandates in children and adults

• Have a Valid Driver's License

• Access to an insured and reliable car

Education & Work Experience

• Bachelor's degree required (social work, psychology, sociology, or public health)

• Master's degree preferred (MSW)

• Minimum of 2 years' experience working in medical, mental health, social or community services required.

• Minimum of 1 years' experience with ages 0-21 years of age (if hired to work with the pediatric