Care Navigator

Equitas Health•Cincinnati, OH

About The Position

The Care Navigator promotes patient-centered medical home concepts and helps patients and families access Equitas Health and community resources. The role assesses social determinants of health and barriers to care, develops patient-centered interventions and care plans, and supports patients in navigating healthcare, social services, benefits, and employment-related resources. Care Navigators collaborate with providers, client services, and the broader care team to support patient outcomes and coordinate services. The position requires accurate, timely, and confidential documentation in Equitas Health, ODH, and other software systems; tracking patient needs and outcomes; and assisting with care-related paperwork, including Ryan White benefits, health insurance, medical procedures, and referrals. Care Navigators communicate with patients, providers, and other stakeholders, attend meetings and trainings, and contribute to committees and performance improvement activities. The role involves travel and attendance at multiple agency sites and community partner locations.

Requirements

Bachelor’s degree in science, social work, or a related field.
Minimum LSW licensure.
Experience working in a multidisciplinary team.
Proficiency in all Microsoft Office applications and other computer applications.
Reliable transportation, a driver’s license, and proof of auto insurance.
Sensitivity to, interest in, and competence in cultural differences, HIV/AIDS, minority health, and sexual practices.
Demonstrated competence working with persons of color and the gay, lesbian, bisexual, and transgender community.

Nice To Haves

Medical and community-based care navigation training experience.
Understanding of NCQA Patient Centered Medical Home, Comprehensive Primary Care Initiative, Accountable Care Organization, or another value-based care delivery model.

Responsibilities

Promote and reinforce patient-centered medical home concepts with patients, families, and the Equitas Health care team.
Participate in developing and implementing an evidence-based standard screening tool for identifying patients’ social determinants of health.
Use screening results to identify factors affecting health outcomes and develop appropriate interventions and care plans.
Help patients access Equitas Health resources and navigate external healthcare and community resources, considering reading level, health literacy, culture, and language needs.
Assess barriers to care and work with patients and families to identify solutions using motivational interviewing and shared decision-making.
Refer patients to community workforce programs and provide supportive services addressing barriers to employment, benefits eligibility, confidentiality, and health management in the workplace.
Collaborate with providers, client services, and the care team on short- and long-term strategies and expected patient outcomes.
Track patient needs and outcomes to support care planning, data collection, and analysis.
Work with providers and the care team to support quality care and patient outcomes.
Assist with completing and submitting documentation related to patient care, including Ryan White benefits, health insurance, medical procedures, and internal and external referrals.
Serve as a link between Equitas Health Medical Center and Client Services to support timely and efficient fulfillment of patient needs.
Maintain patient confidentiality in accordance with Equitas Health policy and procedure, HIPAA, and applicable professional standards.
Maintain documentation in Equitas Health, ODH, and other software systems, ensuring it is complete within one business day of service and reflects best practices and patient-centered, affirming care.
Communicate action items and updates proactively to the Supervisor.
Capture and communicate feedback from patients, families, the Equitas Health care team, and community partners to appropriate persons.
Respond to patient, provider, and other stakeholder correspondence within two business days.
Complete documentation accurately and promptly to support reports to Equitas Health, its Board, and federal, state, and local governments.
Attend assigned trainings to support professional development, best practices, and licensure standards, including Motivational Interviewing trainings and Learning Groups.
Participate in assigned committees and Performance Improvement Teams, as appropriate.
Demonstrate unconditional positive regard and exceptional customer service, and continue developing cultural competency and respect for diversity.
Attend monthly, quarterly, and as-needed meetings in person at agency sites and community partner locations, using telecommunication options for meetings across sites.
Perform other duties related to the position as assigned by the Supervisor.