Care Navigator

Job Summary: The Care Navigator will function as an integral part of the Primary Care Clinic to assess and address patients' needs as related to their resilience/self-determination, ability to access outpatient services, and social determinants of health. This individual will link patients to needed community resources through their work on medical and Integrated Behavioral Heath teams to coordinate services and care that address their medical, mental health, and/or other psychosocial needs of the clinic's patient population. The Social Care Navigator also works with Primary Care teams to outreach and engage patients with complex health and/or psychosocial needs, including those who are high utilizers of hospital and Emergency Department services, and may supervise students in disciplines appropriate to the Navigator's educational background and qualifications. This is a limited term, grant funded position.

Essential Duties and Responsibilities: Functions as an integral part of the Integrated Behavioral Health and Patient Support Services teams attending huddles, team meetings, and coordinating services as assigned by their supervisor. Partners with the Social Health Program Manager to provide care navigation and resource coordination for patients enrolled in Social Health programs, including the Health-Related Social Needs (HRSN) Housing Program and Nutrition Program. Assesses and addresses social and health-related needs to improve access to and utilization of appropriate primary care, behavioral health, and wellness services, with the goal of helping improve patient health outcomes and overall health literacy. Supports Community Health Workers (CHWs) in the coordination and delivery of wellness activities, health education programming, and community outreach efforts to promote patient engagement and health literacy. Maintains accurate and confidential patient-participant records, coordinates referrals, outreach, and follow-up activities, and serves as a liaison between patients, internal care teams, and Social Health programs to facilitate timely access to healthcare, community resources, and supportive services. Assesses patients' social determinants of health and health literacy, utilizing screening tools and questionnaires to assess the patient's living situation, safety, cognitive abilities or status, history of or current substance misuse, physical or mental health needs, intimate partner violence, and other psychosocial needs. Build rapport and supportive relationships with patients to improve utilization of necessary and appropriate primary care, behavioral health, wellness, and social services. Uses motivational interviewing to assess and support the patient's engagement in care and confidence in carrying out a self-management plan. Participates with the care team in developing comprehensive care plans and communicates with the primary care team, documenting all patient contacts in the electronic health record (EPIC) in a timely manner. Provides culturally and role appropriate health education and information to patients. Assist patients in understanding and appropriately using health care and community resources. Works with Primary Care and IBH teams to outreach patients with complex health and/or psychosocial needs and those who are high utilizers of hospital and Emergency Department services in order to remove barriers to care. Provides community-based support with patients, including home or hospital/ED visits and/or patient accompaniments to medical or social service appointments. May facilitate, coordinate, and organize group education, if approved by the supervisor and in consultation with the site management team. May supervise students in disciplines appropriate to the Navigator's educational background and qualifications. Attend regular trainings as required. Performs other duties as assigned. Handles protected health information in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

HIPAA Requirements: The Care Navigator will have access to PHI in the course of their duties. The Navigator will use PHI to schedule patients, transport patients and coordinate care for patients. Applying the minimum necessary standard of HIPAA, the designated record sets to which this employee will have access include the full medical record, the scheduling and demographic functions of the practice management system. Knowledge, Skills and Abilities Required:

• Bilingual/bicultural proficiency preferred.
• Desire to work with underserved communities.
• Desire to work with complex patients including those who may be struggling with mental health and/or substance use.
• Cultural competency.
• High level of skill in interpersonal relations and problems solving.
• High energy and self-directed individual with excellent interpersonal, problem solving, organizational and computer skills.
• Ability to travel to clinics, home visits, and agency visits, etc. in a reliable, confidential and timely manner.
• Ability to take initiative to proactively organize and manage the responsibilities of the job.
• High degree of integrity and professionalism.
• Good working knowledge of available social service resources or skills to acquire knowledge and information expeditiously.
• Ability to work in challenging environments in the community at large and in patients' homes.
• Ability to work as an integral part of a high functioning team.
• Highly proficient with Microsoft Office applications (Word, Excel, PowerPoint, Outlook).Excellent Customer Service skills.
• Commitment and alignment to Virginia Garcia's mission, vision and values.
• Valid driver's license, reliable transportation, safe driving record and insurance coverage required.
• Education and Experience Required:
• Bachelor's degree in a relevant field or minimum four years of college education, preferably in psychology, social work, human services or health-related field required, or equivalent combination of education and experience.
• Meet criteria for QMHA in the state of Oregon (requires a bachelor's degree in behavioral health or alternatively a combination of three years of relevant education and occupational experience).Training in Motivational Interviewing, skills training and case management preferred.
• Current CPR certification.
• Experience with group facilitation.
• Prior EMR experience preferred.

Behavioral Competencies: Accountability: Role model VG's mission, vision, and shared values. Customer-Focus: Listen to the voice of the customer and strive to delight them by exceeding their expectations. Teamwork: If someone needs help, help them. Initiative: Be innovative, apply fresh ideas, and continuously improve how you do your work. Confidentiality: Maintain strict confidentiality and respect the privacy of others. Ethical: Demonstrate integrity, honesty, and stewardship in all encounters at work. Respect: Demonstrate consideration and appreciation for co-workers and patients. Communication: Demonstrate the ability to convey thoughts and ideas as well as understand perspective of others.

Physical Requirements: Percentage of time spent Standing: up to 20%Walking: 25%Sitting: up to 50%Reaching: 5%Must be able to lift/carry up to 20 lbs.: infrequent 20-40 lbs. Local travel: up to 75%Working Environment/Physical Hazards:

• Potential exposure to Blood Borne Pathogens.
• Work environment includes working in patient's homes.
• Equipment Used:
• May use Clinic Vehicles
• Computer – data entry and word processing
• Telephone, Fax, Copier, Printer, Scanner
• Medical equipment:
• Pulse Oximeter
• GlucometerImmunization: Staff member must meet immunization requirements as stated in VGMHC's immunization policy and state and federal guidelines.