Community Health Navigators (CHN) are non-clinically licensed health care staff members who are frontline public health workers deployed in clinical and community care settings to improve the social health of Neighborhood Health Center (NHC) patients in the communities we serve. Navigators act as the quarterback of the care plan for members who have unmet social, medical, and behavioral needs. They work with patients, families/ caregivers, medical providers, and community partners to coordinate care and services across the continuum. Navigators are highly trained communicators and subject matter experts, skilled in Motivational Interviewing and responsible for ongoing community and NHC resource knowledge. Through building strong relationships and trust with patients and their family/caregivers, they can activate clinical care plans, identify patient-centered goals, and connect members to needed community resources to improve health outcomes and reduce total cost of care. The goal of the patient navigators is to help our members with real life issues that create barriers to their total health goals. Additionally, patient navigators outreach to our post behavioral health hospital discharge ready paneled patient population, and patients with recent emergency room visits for primary reason being behavioral health.

Essential Job Duties

• Assist patients with social issues like houselessness, substance abuse and mental health resources, and food insecurity resources, and assess need through social determinants of health (SDOH) screenings.
• Assist patients with organizing their medical care by making follow-up appointments, filling prescriptions, and connection to specialty health as needed.
• Support patients through providing resources to connect to benefits and public assistance program; examples are health insurance, food stamps, and other resources as needed.
• Initiate a follow-up call to patients who have been discharged from the emergency department or hospital following behavioral health crises within 24-48 hours post discharge. Assess and offer mental health resources, SDOH screening, care coordination, and scheduling with behavioral health and clinical pharmacy post hospital or ED visits.
• Build rapport with patients to engage them in their care plan, offering encouragement and guidance in addressing their behavioral health needs.
• Collaborate with the primary care team, Behavioral Health Consultants (BHCs), and external providers to ensure smooth transitions of care and continuity of services for patients’ post-discharge.
• Assist patients in scheduling follow-up appointments with behavioral health providers, primary care physicians, or other relevant services.
• Connect patients to community resources that address social determinants of health (e.g., housing, food, transportation) that may impact their mental health or substance use recovery.
• Identify patients at risk for further crises and escalate cases to the care team or appropriate emergency services as needed.
• Maintain accurate records of patient interactions, interventions, and referrals in the electronic health record (EHR) system.

• Conduct regular follow-ups with patients to assess their progress, adherence to care plans, and any new or ongoing needs.
• Communicate all care and coordination activity, risks and care plans using standard documentation, information technology and care coordination tools in the electronic medical record.
• Be the system coordinator and point of contact for patients and families. May assume advocate role on the patient’s behalf to ensure approval of the necessary services or accessibility of needed resource(s) for the member in a timely fashion.
• Create collaborative relationships with staff across departments within Neighborhood Health Center, and externally, to promote collaboration and multi-system coordination.
• Increase access to health and heath care services through innovative health models, virtual care strategies and collaborative community partnerships.
• Apply motivational interviewing and patient centered approaches to address concerns around barriers to healthcare needs to improve the care experience and motivate patients to meet their health goals.
• Ability to work independently with accountability and exercise sound judgment, discretion, and professionalism at all times.
• Good organizational and time-management skills.
• Other duties as assigned.
• Ability to travel up to 80% of the time and independently meet with patients in the clinic, home, or community-based setting.
• Ability to work across various primary care clinics within NHC.
• Participate in on-site events, clinics, and outreach initiatives as assigned.

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