Community Resource Navigator

OUTER CAPE HEALTH SERVICES INC•Wellfleet, MA

3d•$22 - $27•Onsite

About The Position

The Community Resource Navigator conducts community-based assessments of social determinants of health and wellness needs, helps community members connect with available resources and supports, collects and documents required data, and provides short-term care coordination and individualized care planning. The position reports to the Navigator Program Manager and works with clients, OCHS clinicians, and community representatives to connect participants with appropriate services and treatment options. The Navigator identifies and enrolls eligible participants, assesses their needs, builds and maintains relationships with clients and partner agencies, and coordinates referrals and follow-up. The role includes documenting assessments and progress in required systems, including Epic, and participating in program, behavioral health, departmental, and staff meetings as required.

Requirements

High school degree or equivalent.
Valid Massachusetts driver’s license, or ability to obtain one.
Excellent interpersonal, communication, and organizational skills.
Computer experience and ability to work collaboratively as part of a team.
Excellent written and verbal communication skills.
Working knowledge of computers and demonstrated computer skills, including Outlook, Microsoft Office, and OneDrive.
Excellent judgment and ability to solve problems in a timely manner.
Ability to adhere to strict confidentiality standards.
Demonstrated ability to work effectively both as a team member and independently.
Demonstrated ability to work in a culturally diverse and inclusive environment.

Nice To Haves

Bachelor’s-level education.
Experience with Epic or another electronic medical records system.
Lived experience as a consumer of mental health or substance use services.
Experience engaging clients with mental health, substance use, trauma, and related social service challenges.
Case management, navigation, or community health worker experience.
Bilingual skills.

Responsibilities

Identify at-risk individuals, contact them, explain program benefits and risks, enroll interested and eligible participants, collect required data, and deliver services.
Meet with representatives of partner agencies—including human services, healthcare providers, law enforcement, hospital emergency departments, courts, emergency medical teams, social services, and housing agencies—to build and sustain relationships.
Coordinate community human services and related resources on participants’ behalf.
Establish contact with identified clients and build and maintain effective relationships.
Assess each client’s history and needs using assigned screening and assessment tools.
Maintain contact with clients at a frequency appropriate to their needs and available resources to support adherence to service plans.
Track patient progress through contact and ongoing reassessment, and enter required data into systems such as Epic.
Develop treatment plans with clients, OCHS clinicians, and community representatives, connecting clients with appropriate services and treatment options.
Help clients navigate and use wrap-around support and healthcare services.
Facilitate and coordinate follow-up case conferences with referring agencies.
Coordinate referrals to community substance abuse and mental health services as needed.
Collect and enter program data to support assessments, tracking, patient registry, chart reviews, and patient satisfaction surveys.
Participate in CRN program, behavioral health, departmental, and general staff meetings and agency committees as required.
Coordinate transitions to OCHS programs such as OBAT, Healthy Connections, or Care Coordination with referring resources, including hospital and other organization navigators, as assigned.
Adhere to established case management standards of care and OCHS policies and practices.
Perform other duties and projects as assigned.