Community Care Navigator-Population Health

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.

SPECIFIC RESPONSIBILITIES:

Engages and interacts with patients and/or family members to obtain and document accurate histories, build a trusting relationship, and implement 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.

This role description is a general description of the essential job functions. It is not intended to describe all the duties the Care Navigator may perform.

KEY COMPETENCIES:

• 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, especially in complex and difficult situations, to ultimately provide the best care possible to our patients and their families.

• Decision Making

Ability to make the most appropriate decision in a given situation and then taking the next steps to ensure appropriate and timely completion. This requires conflict resolution skills, critical thinking skills, confidence in your ability to make the right decision in most situations. This also includes ability to prioritize your workday appropriately to ensure the most important tasks are completed on time.

• HealthCare Knowledge

Having the drive to keep yourself abreast and up to date on the new breakthroughs in your area of expertise and communicating them to the rest of the team, as appropriate. This also includes keeping up with your licensure and yearly training requirements within your area expertise along with MAHEC's organizational training. Finally, the ability to apply the depth of knowledge maintained and gained through this process in real life scenarios as appropriate.

• Interpersonal Skills

Showing the ability to meet difficult situations with grace, professionalism, and understanding. Within your area of expertise, showing respect and showing empathy where appropriate with your colleagues, patients, and their family at all times, even when its most difficult to do so. This is done, in part, by effective listening, being your authentic self, showing responsibility and dependability, and being patient with others.

• Organizational Values

Adherence to MAHEC's founding principles and incorporating them every day. This includes, among others, having integrity and accountability, reverence for other cultures and equitable practices, ability to manage change, and displaying a clear understanding of organizational dynamics. Doing these things creates a culture where people want to do the best for each other and gives personal ownership towards the goal of helping people in their time of need.

• Problem Solving

Having an analytical mind and ability to work autonomously to solve complex problems that may arise. The wherewithal to think logically through a difficult problem and come to an appropriate resolution for a given issue. This helps to drive continuous improvement by thinking through where we can improve in a novel way. Measures success by understanding where we are currently and where we want to go and then applying those new ideas to affect positive change.

SPECIFIED SKILLS

• Computer proficiency - electronic health record or care management platform experience preferred.
• Ability to flourish in a team system that supports equity and inclusion.
• Excellent skills in Microsoft Office including Word, Excel, PowerPoint, and database applications required.

PREFERRED SKILLS:

• Entry-level proficiency in another language such as Spanish, Russian or Ukrainian preferred.

PHYSICAL DEMANDS:

• Not Applicable

SUPERVISORY RESPONSIBILITIES:

• Not Applicable

EDUCATION OR EXPERIENCE:

Required -Associate's degree in health related field, two years of undergraduate education in the social sciences or certification or license in a related field of study

Preferred - Bachelor's degree in social work or other Social Science, Community Health Worker, Certified Health Education Specialist (CHES) or Peer Support Specialist. 3 years of experience in health care.

SCHEDULE:

Monday - Friday, 8:00 am to 5:00 pm (or flexed to best meet the needs of the clients and/or the Division); 40 hours per workweek; weekend, holiday, or evening coverage is occasionally required. Work hours will need to be flexible in order to respond to special work assignments, or evening activities, as requested by the team leader.

Position Compensation: $48,500, full time with full benefits