Community Health Navigator

WELLBE INTRODUCTION

The WellBe care model is a Physician Led Advanced Geriatric Care Program focused on the quality of care of the frail, poly-chronic, and elderly Medicare Advantage patients. This population is typically underserved and very challenged with access to overall health care. To address these problems, we have elected to bring the care to the patient, instead of trying to bring the patient to the care. WellBe’s Care Model is to provide our members the entire continuum of care from chronic to urgent care in the home, hospital, skilled nursing facility, assisted living, palliative care, and to end of life care.  WellBe's physician/advanced practicing clinician led geriatric care teams’ partner with the patient’s primary care physician to provide concierge level geriatric medical care and social support in the home as well as delivering and coordinating across the entire care continuum.

GENERAL SUMMARY

The Community Health Navigator (CHN) is responsible for helping patients, families, and community teams to navigate and access services and resources in each community served. The CHN supports the social workers and community teams through an integrated approach to care management and community outreach. CHN’s will prioritize activities to promote and improve the health of patients and their families.

SKILLS & COMPETENCIES

• Responsible for establishing trusting relationships with patients and their families while providing general support and encouragement.
• Follow up with patients via phone calls and visits to home settings and community settings where patients reside.
• Provide connections* for services to community agencies as appropriate and identified.
• Help patients connect with transportation resources and provide appointment reminders where needed.
• Work closely with providers and patients, exhibiting excellent working relationships and effective communication.
• Knowledge of community resources appropriate to the needs of patients and families.
• Responsible for providing consistent communication to the social workers and community teams when necessary.
• Attend and participate in SW Council, team huddles, interdisciplinary teams (IDT), and trainings when requested and necessary.
• Act as a patient advocate and liaison between community service agencies and patients and families.
• Assist with monitoring program eligibility for attributed WellBe patients.
• Document accurately and timely into the EMR for supporting up to date communication information in charts.
• Excellent organizational skills to handle multiple priorities, remaining professional and calm.
• Ability to work with diverse populations respectfully and patiently.
• Ability to work somewhat independently and be self-directed and flexible.
• Ability to perform functions with minimal supervision.
• Performs other duties as assigned.

QUALIFICATIONS

Educational Requirements:

• Bachelor’s degree in Social Work, HDFS, counseling or psychology preferred
• Community Health Worker Program Certification preferred

Required Skills and Abilities:

• 2+ years healthcare background experience, preferably in behavioral health, human development and family services, counseling, psychology, or social work required.
• Strong collaboration and communication skills
• Able to work within and cross departmentally effectively and efficiently

Travel requirements:

• Travel may be required up to 50% locally

Work Conditions:  

• Standard office work conditions of sitting at desk and using electronic devices for long periods of time
• Office temperatures may vary

The preceding functions may not be comprehensive in scope regarding work performed by an employee assigned to this position classification.  Management reserves the right to add, modify, change, or rescind the work assignments of this position.  Management also reserves the right to make reasonable accommodations so that a qualified employee(s) can perform the essential functions of this role.