Care Navigator

Impact Health•Asheville, NC

17d•$47,000 - $50,000•Hybrid

About The Position

Impact Primary Care Network is a physician-led clinically integrated network (CIN) that is leading a new approach to delivering whole-person care in Western North Carolina (WNC). IPCN is deeply invested in patient health and the health of this rural region. The care management platform and services are designed to seamlessly integrate social health support with clinical care to improve patient health outcomes. IPCN supports primary care practices participating in innovative population health initiatives like NC Medicaid’s Managed Care Plans and Healthy Opportunities Pilot (HOP). IPCN was founded by Impact Health, a nonprofit that leads innovative strategies to bridge social and clinical systems of care in Western North Carolina and across the nation. IPCN is the nonprofit clinical arm dedicated to integrating social and primary care through high-quality care management across Western North Carolina. When you join IPCN, you join a network focused on achieving key healthcare transformation goals, including: Better patient experience Improved population health Lower healthcare costs Improved provider satisfaction Health equity Position Summary The Care Navigator is a key member of the IPCN care management team, supporting population health initiatives for managed Medicaid members. Collaborating closely with Nurse Care Managers, the Care Navigator identifies and addresses social determinants of health (SDOH), connects patients to community-based resources, and supports transitions of care (TOC) following hospital and emergency department discharges. With appropriate clinical supervision, the Care Navigator provides basic health coaching for patients with chronic conditions, conducts telephonic outreach, and engages directly with patients and primary care practices to promote timely follow-up care, improved health outcomes, and enhanced patient experience. This role serves as a liaison among patients, network practices, community agencies, and the broader care team to ensure coordinated, patient-centered care.

Requirements

Associate’s degree in social work, or related field, with required work experience
Associate’s degree requires two years’ experience in direct client services, community-based programs, relevant clinical or social service settings, or eligibility screenings
Proven delivery of quality customer service
Knowledge of needs and issues related to social determinants of health
Excellent customer service and problem-solving abilities
Effective communication skills and etiquette – both verbally face-to-face and by phone, and written by email, text, and record keeping
Displays empathy and patience to consumers and coworkers
Understanding medical documentation and electronic medical records
Demonstrates a high degree of cultural awareness and sensitivity when working with vulnerable populations
Highly responsible, organized, and accountable
Understands and protects patient privacy as it relates to HIPAA
Projects a positive, service-oriented attitude and desire to enhance the quality of assigned tasks
Highly adaptive and able to perform well in an evolving team environment
Applicants must have a valid North Carolina driver’s license and must have reliable access to their own vehicle.

Nice To Haves

Bachelor's degree in social work or a related human service field
Medical/clinical setting experience
Experience with diverse populations.
Experience partnering with individuals and families with complex needs
Knowledge of NCCARE360
Bilingual is a plus
Applicants must be committed to living within and performing hybrid work in the 18-county WNC region served.

Responsibilities

Social Care Navigation
Develop, maintain, and utilize extensive knowledge of internal and external social and medical resources in WNC.
Identify and assess social determinants of health (SDOH) needs through patient outreach, screening tools, and collaboration with health plans, providers, and clinical teams
Connect patients to appropriate community-based resources (e.g., food assistance, housing support, transportation, personal safety, social services) and support follow-through on referrals
Utilize NCCARE360 or other referral platforms as appropriate
Develop and maintain appropriate care plans for SDOH needs by creating SDOH-specific SMART goals and monitoring progress toward completion of identified goals
Clinical Care Navigation
Conduct post-hospital and emergency department discharge outreach (TOC) to ensure patients understand discharge instructions and receive timely follow-up care
Coordinate with primary care practices to schedule follow-up appointments and address barriers to care
Support IPCN care team with referrals and individualized care planning for addressing medical, social, and emotional needs
Provide basic health coaching and education for patients with chronic conditions (e.g., diabetes, hypertension, asthma), under the clinical supervision of Nurse Care Managers
Escalate clinical concerns, complex needs, or barriers to Nurse Care Managers, supervisor, or other appropriate team members
Understand and support the achievement of IPCN-identified Quality goals
Engagement
Perform telephonic outreach to patients to assess needs, support engagement, care plan adherence, and self-management goals
Spend scheduled time embedded in primary care practices within the IPCN Network to collaborate with practice providers and staff and meet patients face-to-face when appropriate
Serve as a liaison among patients, IPCN care team, primary care practices, and community agencies to promote coordinated care and healthy patient outcomes
Support population health initiatives and quality improvement efforts related to care transitions, SDOH, preventative health, chronic condition management, and patient engagement
Participate in team meetings, training, and ongoing performance improvement activities as assigned
Technology and documentation
Competently utilize assigned technology platforms (e.g., Innovaccer, various practice electronic health records (EHR), NCCARE360)
Document patient interactions, assessments, care plans, referrals, and outcomes accurately and timely in designated care management or electronic health record systems
Develop and maintain care plans for SDoH needs by setting clear goals, developing structured approaches to support SDoH needs, and collaborating with clients, other health care providers, and HOS personnel to ensure resource utilization.
Provide technical assistance to others around SDOH screening, referrals, and using NCCARE360
Maintains an appropriate working knowledge of applicable Federal, State, and local laws and regulations, as well as payor agreements, and Impact Health and IPCN policies