Community Health Patient Navigator

Memorial Hermann Health System

2d•Onsite

About The Position

At Memorial Hermann, the Patient Care Navigator provides in-person support to patients in clinical settings such as emergency departments, inpatient units, or outpatient clinics. This role focuses on identifying and addressing non-medical drivers of health (NMDOH), supporting behavior change through advanced motivational interviewing, and helping patients transition to stable care in the community. The Patient Navigator rounds, engages patients with compassion and humility, and collaborates closely with care coordination teams such as social workers, case managers, and clinical staff, to align support plans and facilitate connections to internal and external resources upon discharge. This role plays a key part in reducing avoidable emergency room (ER) utilization and preventable readmissions among vulnerable patients with chronic or ambulatory care sensitive conditions. The Patient Navigator is responsible for timely documentation in EPIC, and identifying patterns or gaps impacting patients, which connects to broader system goals within the Community Health Network.

Requirements

High school or GED required.
One of the following is required: Community Health Worker (CHW) by the Texas Department of State Health Services (TDSHS), Community Health Worker - Instructor (CHW-I) by the Texas Department of State Health Services (TDSHS), Community Health Worker -Experience (CHW-E) by the Texas Department of State Health Services (TDSHS), Community Health Worker - Training (CHW-T) by the Texas Department of State Health Services (TDSHS).
Effective oral and written communication skills, with the ability to build trust and rapport across diverse populations.
Must be comfortable navigating digital documentation and referral systems.
Strong knowledge of NMDOH and an understanding of community resources.
Strong organizational and time management skills, with the ability to manage multiple referrals and follow-ups.
Ability to work collaboratively as part of a multidisciplinary team while maintaining empathy, discretion, and professionalism.
Experience using Microsoft Suite (Word, Excel).

Nice To Haves

Associates degree in related field preferred.
Certified Patient Navigator (CPN) by the Patient-Centered Education & Research Institute and Academy of Oncology Nurse & Patient Navigators (AONN+).
Motivational Interviewing Certificate or training completion by the Texas Department of State Health Services (TDSHS) or Texas Health and Human Services (HHSC).
Minimum three (3) experience in healthcare or hospital settings, especially with underserved or high-risk populations, preferred.
Experience providing in-person support to patients at the bedside in hospital or clinical settings.
Bilingual (Spanish) strongly preferred.
EPIC or other EHR experience preferred.

Responsibilities

Conducts screenings to identify NMDOH and accurately documents patients’ risk levels for each domain (e.g. housing, food, utilities) within the designated electronic medical record system (e.g. EPIC) and to determine eligibility for public assistance and community support programs.
Uses advanced motivational interviewing techniques to engage patients in behavior change, build trust, and explore readiness for action.
Collaborates with care coordination teams (e.g. social workers, case managers), to develop and implement discharge support plans that address both clinical (e.g. medical home placements, prescription assistance) and non-clinical factors related to NMDOH uninsured and underinsured patients.
Refers patients to appropriate internal and external resources, including medical homes, community-based organizations, and support programs, ensuring alignment with patient needs and eligibility.
Documents all interactions, screenings, and referrals in Epic, ensuring accurate tracking of NMDOH indicators, navigation outcomes and follow-up needs.
Identifies and tracks trends, common barriers and service gaps experienced by patients and escalate insights to program leadership to inform Community Health Network strategies and care design.
Participates in community-based activities to identify new resources while maintaining longstanding partnerships that enhance patient navigation and represent Memorial Hermann at special events or programs in support of broader community health initiatives.
Provides support, as needed, at other locations outside of the designated Memorial Hermann site, that align with the Community Health Network including but not limited to Community Resource Centers, Food as Health sites, Community Health Worker Hub, to meet patient and program needs.
Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences.
Models Memorial Hermann’s service standards of providing safe, caring, personalized and efficient experiences to patients and our workforce.
Other duties as assigned.