Community Health Patient Navigator

Memorial Hermann Health System

About The Position

The Community Health Patient Navigator provides in-person support to patients in emergency departments, inpatient units, and outpatient clinic settings. The role identifies and addresses non-medical drivers of health (NMDOH), uses motivational interviewing to support behavior change, and helps patients transition to stable community care. The navigator rounds, engages patients with compassion and humility, and collaborates with social workers, case managers, clinical staff, and other care coordination teams to align support plans and connect patients with internal and external resources, including at discharge. The role helps reduce avoidable emergency room utilization and preventable readmissions among vulnerable patients with chronic or ambulatory care sensitive conditions. The navigator documents screenings, interactions, referrals, and outcomes in EPIC or another electronic medical record; identifies patient barriers and service gaps; and shares patterns with program leadership to inform Community Health Network strategies and care design. The position typically reports to a Manager within the Community Health Network’s ER Navigation Program and/or Inpatient Navigation Program. The navigator may provide support at other Community Health Network locations, including Community Resource Centers, Food as Health sites, and the Community Health Worker Hub.

Requirements

High school diploma or GED.
One of the following Texas Department of State Health Services credentials: Community Health Worker (CHW), Community Health Worker - Instructor (CHW-I), Community Health Worker - Experience (CHW-E), or Community Health Worker - Training (CHW-T).
Experience providing in-person support to patients at the bedside in hospital or clinical settings.
Effective oral and written communication skills and the ability to build trust and rapport across diverse populations.
Strong knowledge of non-medical drivers of health and understanding of community resources.
Strong organizational and time management skills, including 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, including Word and Excel.

Nice To Haves

Associate's degree in a related field.
Certified Patient Navigator (CPN) certification through the Patient-Centered Education & Research Institute and Academy of Oncology Nurse & Patient Navigators (AONN+).
Motivational Interviewing Certificate or training completion through the Texas Department of State Health Services (TDSHS) or Texas Health and Human Services (HHSC).
At least three years of experience in healthcare or hospital settings, especially with underserved or high-risk populations.
Bilingual Spanish.
Experience with EPIC or another electronic health record system.

Responsibilities

Screen patients for non-medical drivers of health and document risk levels for domains such as housing, food, and utilities in the designated electronic medical record.
Determine patient eligibility for public assistance and community support programs.
Use motivational interviewing techniques to engage patients in behavior change, build trust, and explore readiness for action.
Collaborate with care coordination teams to develop and implement discharge support plans addressing clinical and non-clinical needs, including medical home placement and prescription assistance.
Refer patients to appropriate internal and external resources, including medical homes, community-based organizations, and support programs, based on patient needs and eligibility.
Document interactions, screenings, referrals, NMDOH indicators, navigation outcomes, and follow-up needs in EPIC.
Identify and track trends, common barriers, and service gaps, and escalate insights to program leadership.
Participate in community-based activities to identify resources, maintain partnerships, and represent Memorial Hermann at events and programs supporting community health initiatives.
Provide support at other Community Health Network locations as needed to meet patient and program needs.
Promote safe care for patients, staff, and visitors, and follow organizational policies, procedures, and standards for time management, supply management, productivity, and quality of service.
Meet mandatory and continuing education and skills competency requirements; support department goals; and serve as a preceptor, mentor, and resource to less experienced staff.
Model Memorial Hermann service standards by creating safe, caring, personalized, and efficient experiences for patients and the workforce.
Perform other duties as assigned.