Community Health Navigator - NJ

Medzed LLC•Newark, NJ

5d•$25 - $30•Onsite

About The Position

MedZed delivers value-based, technology-enabled social support to high-cost Medicaid members who have been unreachable through traditional telephonic outreach, disconnected from primary care, and frequently rely on hospital-based services as their primary point of care. We combine innovative technology with field-based outreach to engage members, reconnect them to appropriate healthcare providers, address Health-Related Social Needs (HRSNs), and empower members to take greater control of their health. Our interventions are designed to reduce avoidable Emergency Department and Inpatient utilization while improving health outcomes and quality of life.

Requirements

High school diploma or equivalent required.
Community health, healthcare, outreach, or care coordination background strongly preferred.
Experience working with Medicaid populations, healthcare navigation, community outreach, or social service programs preferred.
Strong communication, relationship-building, motivational interviewing, and problem-solving skills.
Ability to establish trust and effectively engage hard-to-reach members.
Comfortable working independently in community settings.
Strong organizational skills with the ability to manage a caseload of 45–55 members.
Ability to prioritize daily activities and meet established productivity, program, and SLA expectations.
Strong attention to detail and commitment to timely documentation and follow-up.
Proficiency with electronic documentation systems and basic technology.
Ability to work collaboratively with RNs, Territory Managers, providers, community organizations, and other members of the care team.
Commitment to member-centered care, accountability, quality, and successful program outcomes.
Valid driver's license required.
Reliable transportation required.
Proof of active automobile insurance required.
Ability to travel daily throughout the assigned territory.
Ability to conduct visits in members' homes, hospitals, healthcare facilities, community organizations, and other approved locations.
Ability to work independently while maintaining communication with the internal team.
Flexibility to adjust daily routes and schedules based on member needs and program priorities.
This position requires regular automobile travel to client homes and other locations which may involve driving, walking, standing, and navigating indoor and outdoor environments, including stairs and uneven surfaces.
The employee must be able to safely operate a motor vehicle and maintain a valid driver’s license and automobile insurance, as required by job duties and applicable law.
The employee may occasionally be required to carry and transport work-related materials or equipment weighing up to 10 pounds.
The employee must be able to communicate effectively in person, by telephone, and through electronic communication methods while performing job duties in field and remote settings.
The employee must be able to sit, stand, walk, bend, reach, and use hands and fingers to perform essential job functions.
Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions of the position, in accordance with applicable federal and state law.

Nice To Haves

Certified Nursing Assistant (CNA)
Certified Medical Assistant (CMA)
Patient Care Technician (PCT)
Community Health Worker (CHW)
Care Coordinator or Care Navigator
Behavioral Health Technician
Home Health Aide (HHA)
Public Health or Health Education professional
Equivalent experience in community outreach, care coordination, case management, member engagement, healthcare navigation, or community-based healthcare programs will also be considered.

Responsibilities

Identify, find, and locate eligible members through field outreach, community canvassing, telephone outreach, and other approved outreach strategies.
Conduct face-to-face outreach in hospitals, members' homes, community locations, and other appropriate settings.
Establish rapport and build trust with members who may have previously been difficult to reach.
Explain the program and obtain informed member consent prior to enrollment.
Complete required enrollment and assessment activities accurately and timely.
Maintain a consistent pipeline of potential members to support program enrollment goals.
Manage and maintain a consented caseload of 45–55 members.
Maintain successful engagement with members throughout the entire enrollment period. Members should have at least two successful contacts per month.
Develop individualized relationships and support members in achieving their care plan goals.
Conduct timely and consistent follow-up based on member needs, risk level, and program requirements.
Monitor member progress and identify barriers that may interfere with successful program completion.
Re-engage members who become difficult to reach and use appropriate outreach strategies to maintain participation.
Prepare members for successful graduation from the program within the six-month enrollment period.
Assess and address Health-Related Social Needs (HRSNs), including housing, food insecurity, transportation, utilities, behavioral health, and financial and community resource needs.
Connect members with appropriate community-based organizations and resources.
Follow up to ensure members are successfully connected to referred resources and services.
Identify barriers to care and work collaboratively with members to develop solutions.
Connect members to primary care providers, specialists, and other appropriate healthcare services.
Assist members with scheduling appointments and provide follow-up to support appointment completion.
Identify, address, and close assigned healthcare gaps in collaboration with the clinical team.
Educate and coach members on the importance of preventive care and ongoing healthcare engagement.
Support members in establishing and maintaining relationships with appropriate healthcare providers.
Document health metrics, including blood pressure readings and A1C (ALC) numbers, when applicable.
Monitor member progress toward identified health and care plan goals.
Monitor member hospitalizations when information is available.
Provide timely follow-up when a member is hospitalized or discharged.
Coordinate with the internal clinical team regarding hospitalized or high-risk members.
Re-engage members following hospitalization or an Emergency Department visit.
Assist members with reconnecting to providers and community resources following hospitalization.
Escalate clinical, behavioral health, safety, or other high-risk concerns to the appropriate RN or clinical team member.
Document all member encounters, outreach attempts, interventions, referrals, and outcomes accurately and within required timeframes.
Maintain complete and timely documentation in the designated electronic system.
Record required member health metrics and program activities.
Ensure documentation supports program reporting, quality requirements, and member outcomes.
Maintain confidentiality and comply with all organizational, client, and regulatory requirements.
Consistently support and contribute to established program goals and performance metrics.
Meet established Service Level Agreements (SLAs) and productivity expectations.
Maintain an organized daily schedule that prioritizes member needs, outreach, follow-up, and required documentation.
Participate in team meetings, case conferences, training, quality improvement initiatives, and program activities.
Communicate barriers, trends, and opportunities for improvement to the Territory Manager.
Demonstrate accountability for assigned caseload, member outcomes, engagement, documentation, and program deliverables.