Community Resource Navigator (Social Work)

Big Bend Hospice•Tallahassee, FL

5d•Hybrid

About The Position

Big Bend Palliative Care (formerly Transitions Supportive Care), a program of Big Bend Health, is dedicated to improving quality of life for individuals living with serious illness through compassionate, community-based support. Guided by our values of respect, excellence, integrity, accountability, and compassion, we are seeking a Community Resource Navigator (CRN) to support patients and caregivers in accessing essential resources and navigating complex care systems. The ideal candidate for the Community Resource Navigator role is a compassionate and resourceful social work professional who is passionate about supporting patients and families facing serious illness. This individual excels in communication, care coordination, and problem-solving, with a strong understanding of community resources and social drivers of health. They will play a critical role in supporting Principal Care Management (PCM) services through patient outreach, resource coordination, and care plan follow-up, while also serving as a mentor to interns and a key member of the interdisciplinary team.

Requirements

Master’s Degree in Social Work (required).
Minimum of three (3) years of experience supporting patients and/or caregivers coping with serious or advanced illness.
Experience navigating community resources, social services, and benefit programs.
Intermediate computer skills required.
Valid driver’s license, auto insurance, and reliable transportation.
Commitment to Big Bend Health’s core values: respect, excellence, integrity, accountability, and compassion.

Nice To Haves

Prior experience supervising students or interns preferred.

Responsibilities

Conduct outreach to assigned patients and caregivers within 72 hours of referral (or next business day for weekend referrals).
Assess patient and caregiver needs, identify barriers to care, and support care plan follow-up.
Coordinate community resources including transportation, housing, food assistance, utilities, and in-home support services.
Assist patients and caregivers with benefit applications such as Medicaid, long-term care services, and other public assistance programs.
Provide in-person or virtual support, including psychosocial and social needs assessments.
Educate caregivers on coping strategies, self-care, and available community supports.
Maintain and update community resource lists.
Support patient engagement and continuity of care by assisting with follow-through on appointments, services, and applications.
Communicate patient needs, barriers, and changes in condition to appropriate clinicians and team members.
Collaborate with interdisciplinary team members, community partners, case managers, and providers.
Support operations on the mobile medical unit as needed.
Maintain accurate, timely, and compliant documentation in the electronic medical record and program trackers.
Track outreach, interventions, and follow-up activities to support PCM program goals.
Submit weekly productivity reports to leadership.
Supervise and support MSW interns, including training, task delegation, and performance feedback.
Complete required internship evaluations and documentation.
Participate in program development, quality improvement, and professional development initiatives.
Maintain confidentiality and comply with HIPAA and organizational policies.
Perform other duties as assigned.