Community Health Navigator

Vinfen•Allston, MA

4d•$50,000 - $50,000

About The Position

The Community Health Navigator on the Community Partner team provides care coordination and connection to social services and community resources for people with medical and behavioral health needs. The Community Health Navigator is an active member of the Community Partner Care Team which also includes nurses, licensed behavioral health clinicians and a team administrator. The Community Health Navigator is supervised by the Care Team Leader and will learn about community resources, trauma/recovery skills, wellness coaching and how to conduct an assessment and develop a care plan. The Community Health Navigator must be willing to visit clients in their homes as well as work from our office.

Requirements

A High School Diploma or equivalent is required.
Minimum of 3 years care management experience preferred.
Experience working with people living with SMI and/or SUD.
Driving is a requirement for this position using either a Vinfen van or personal vehicle. If using a personal vehicle, you must possess and maintain adequate insurance as well as maintain a safe driving record which is subject to annual checks.
A valid driver's license must be presented at the time of employment.
Incumbents must be at least 21 years of age, have maintained a valid US driver's license for at least six months, and must be able to pass a driver's screening background check.
Ability to stand, walk, bend, kneel, stoop, crouch, crawl, climb as this is a very physically active position.
Must be able to lift at least 25 pounds using proper lifting techniques or the use of a two-person lift.
Ability to operate a computer and other office equipment such as a calculator, copier, and printer.
Ability to sit, reach, climb stairs, and maneuver through narrow spaces or hallways.
Ability to assist clients with tasks of daily living.
Ability to remain in a stationary position 50% of the time as needed.
Ability to bend, reach, file, sit, stand, and move around the facility.
Ability to speak, hear, and communicate with clients, staff, and external representatives.
Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

Nice To Haves

Bachelor's degree in Human Services field strongly preferred
Certified Community Health Worker (CHW) preferred.
Bi-lingual/bi-cultural applicants and those with lived experience of psychiatric conditions are encouraged to apply.

Responsibilities

Outreach to and engage Enrollees of an ACO plan as referred to CP Program.
Coordinate the completion of the Comprehensive Assessment (CA).
Conduct initial and ongoing risk assessment; design personal crisis management plans, relapse prevention and harm reduction strategies with members who have been identified as behaviorally complex in collaboration with team LPHAs.
Coordinate the development, implementation, and ongoing review of the Person Centered Treatment Plan (PCTP) inclusive of any LTSS and / or SDH needs or goals of the Enrollee.
Drive referrals regarding connections to any community or social services that align with the Enrollees needs and goals.
Submit CA, PCTP, and all PCTP updates in accordance with the data sharing agreement CP and ACO/MCO Plan.
Collaborate closely with PCP and other providers, including but not limited to community resources, to assure appropriate referrals based on level of care needed to optimize outcomes and minimize risk.
Communicate and collaborate with ACO/MCO teams and serve as a team resource.
Collaborate with ACO Plan, PCP, and other health care providers regarding changes in services, care transitions, and crisis intervention while focusing on continuity and quality of client care and potential efficiencies and cost-savings.
Obtain required Prior Authorization from ACO/MCO Plan for relevant/necessary services.
Manage all care transitions through collaboration with Enrollee, community provider staff, ICT, and hospital staff to ensure a safe discharge plan and a well-coordinated implementation of that plan.
Ensure for medication review and reconciliation as triggered by a care transition or by a medication change through an outpatient medical or psychiatric visit.
Perform other related duties, as required.