Care Navigator

Glbhc•Saginaw, MI

13d•Onsite

About The Position

The Care Navigator plays a crucial role in ensuring a smooth transition of care for patients from hospitalization back to their primary care setting. This position involves assessing patient needs during hospitalization, coordinating follow-up care, identifying and resolving barriers to care, collaborating with the care team, educating patients and families, and maintaining accurate documentation. The goal is to support patient adherence to follow-up care plans and promote recovery and ongoing health management.

Requirements

High school diploma or GED required.
Minimum of two (2) years of experience in healthcare, care coordination, community health work, patient navigation, or related field required.
Experience working with vulnerable populations or within primary care, hospital discharge planning, or care coordination strongly preferred.
Possesses basic knowledge and skill appropriate to education/training.
Telephone and computer skills.
Flexible in accepting work assignments.
Possesses the ability to seek and utilize supervision appropriately.
Ability to communicate effectively with a diverse patient population.
Professional interpersonal communication skills.
Ability to function as a committed and reliable team member.
Must be able to sit, stand, and or walk for an entire workday.
Must be able to lift, carry, push, pull, and or twist while holding up to 25 lbs. frequently.

Nice To Haves

Associates degree in healthcare, social services, or related field preferred.
Community Health Worker (CHW) certification preferred.
Bilingual (English/Spanish) preferred.

Responsibilities

Establishes direct contact with patients during hospitalization to assess needs, introduce transition support services, reinforce the importance of follow-up care, and begin discharge planning in collaboration with hospital staff.
Serves as a liaison between the hospital team and GLBHC primary care site to coordinate timely follow-up appointments and support continuity of care after discharge.
Facilitates scheduling of hospital follow-up appointments with the patient’s GLBHC primary care site within recommended timeframes.
Conducts post-discharge outreach to confirm appointments, reinforce discharge instructions, and support patient adherence to follow-up care plans in coordination with primary care nursing staff.
Assesses patient barriers to care including transportation, financial concerns, health literacy, insurance coverage, and other social determinants of health.
Works collaboratively with internal staff and community resources to address barriers and facilitate successful attendance at follow-up visits.
Works closely with providers, nurses, care managers, community health workers, and other care team members to support continuity of care following hospital discharge.
Participates in care team meetings, huddles, and case discussions to ensure coordinated care plans for high-risk patients.
Provides guidance and education to patients and families regarding the importance of follow-up care, medication adherence, and available community resources.
Supports patients in navigating the healthcare system and accessing services that promote recovery and ongoing health management.
Maintains accurate and timely documentation of all patient interactions and coordination activities within the electronic medical record and applicable tracking systems.
Monitors and reports transition-of-care performance indicators and assists in quality improvement initiatives related to hospital follow-up care.
Participates in team meetings.