Community Health Navigator

Vinfen•Allston, MA

1d•$50,000 - $50,000

About The Position

Overview 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. The Community Health Navigator will also: Outreach to and engage people referred to the Community Partner program. Coordinate the completion of the Comprehensive Assessment 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 clinicians. Coordinate the development, implementation, and ongoing review of the care plan. Make referrals to any community or social services that align with the persons we are serving needs' and goals'. Collaborate and communicate with the client's other medical, behavioral health providers regarding changes in services, hospitalizations, and other care plan goals Obtain required Prior Authorization from Managed Care Plan for relevant/necessary services. Perform other related duties, as required Responsibilities Summary: The Community Health Worker (CHW) provides care coordination and care management for MassHealth Members with complex medical and behavioral health needs who are enrolled in an Accountable Care Organization (ACO) or Managed Care Organization (MCO) plan. The CHW collaborates with the Community Partner team and the clinical staff of each Enrollee’s ACO/MCO’s plan to minimize duplicative efforts, promote integrated care, ensure quality and continuity of care, and support the values of person-centered planning, Community First, and SAMHSA Recovery Principles. The CHW is at the helm of organizing and coordinating resources and services in response to the Enrollee’s healthcare needs across multiple settings, and inclusive of both LTSS and SDH needs. This role drives outreach and engagement, assessment and care planning, care transitions, health and wellness coaching, as well as community and social services connections in partnership with Enrollees and their care teams.

Requirements

Strong commitment to the right and ability of people served to live, work, have meaningful relationships, and receive the resources and supports needed in their community of choice
Knowledge of person-centered, strengths-based, recovery-oriented values and principles and modalities
Knowledge of clinical and psychiatric rehabilitation values, principles, and techniques
Knowledge of health risks of prevalence with adults with SMI/SUD
Knowledge of health promotion and clinical care coordination techniques
Knowledge of motivational interviewing, stage of change, and harm reduction techniques
Knowledge of trauma-informed and culturally responsive services
Sensitivity to the cultural, religious, ethnic, disability, and gender issues
Skills and competence to establish supportive trusting relationships with Enrollees
Knowledge of human, legal, civil rights, community, and other resources
Knowledge of empowerment and self-advocacy techniques
Knowledge of available community health, mental health, and SUD services and resources
Ability to triage/balance competing priorities
Ability to make independent judgments and decisions
Ability to work in a professional and confidential capacity
Ability to work independently and as member of a multidisciplinary team
Minimum of 3 years care management experience preferred.
Experience working with people living with SMI and/or SUD.
A high school diploma or equivalent is required
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 one year, 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.
For positions in day programs or group residences, the ability to assist in routine living activities including cleaning, meal preparation, vacuuming, shoveling, and grocery shopping.
CPR is required within two weeks of hire
First Aid is required within two weeks of hire
All candidates for this position must be a least 21 years of age and be able to pass a CORI, driving record, reference, multi-state background check

Nice To Haves

BA/BS in human-services related field preferred.
Preference given to bi-lingual/bi-cultural applicants and those with lived experience of psychiatric conditions.
Certified Community Health Worker (CHW) preferred.
A minimum of 1 year of case management experience; 2-3 years preferred.
Experience working with people living Serious Mental Illness and/or Substance Abuse Disorder strongly preferred
Strong organizational and collaboration skills
Ability to prioritize work tasks and work both independently and as part of a multi-disciplinary team
Ability to effectively represent the organization in a variety of circumstances and forum

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.

Benefits

A fully funded, employer-sponsored retirement plan that requires no employee contribution as well as an employee-funded 403(b) plan
First-rate Medical, Dental and Vision plans that are open all employees scheduled to work 30 hours per week or more. Plus, we offer a generous employer contribution toward the cost of medical insurance!
Employer-paid Life, Accidental Death & Dismemberment and Long-Term Disability Insurance (no cost to you!)
Employer-paid Short-Term Disability Insurance along with the option to purchase additional, voluntary, Short-Term disability insurance
Flexible Spending Reimbursement Accounts (Health and Dependent care)
Voluntary Term, Whole Life, Accident and Critical Care Insurance
Generous paid time off (Employees scheduled to work 20 hours or more per week)
Educational Assistance and Remission Programs
$500 Employee Referral Bonus with no annual cap!
Other generous benefits including discounted YMCA memberships, access to discounted movie tickets and more!