Health Navigator/Care Coordinator, Care Management Services (CMS)
About The Position
The Health Navigator/Care Coordinator, within the Care Management Services (CMS) department, is responsible for assessing and engaging clients in health and wellness initiatives and developing comprehensive care plans. This role involves building rapport with clients, administering health and psychosocial screenings, and collaborating with a care team to achieve optimal health outcomes. The position requires implementing care plan tasks, ensuring continuity of care, and documenting all interventions. Responsibilities also include conducting home visits, working with family members, providing transitional care post-hospitalization, and facilitating care delivery by scheduling appointments and arranging transportation. The role utilizes evidence-based practices like motivational interviewing and identifies community resources for referrals. The Health Navigator/Care Coordinator also manages Client Service Dollars (CSD) and participates in team meetings and clinical conferences.
Requirements
- B.A. or M.A. degree in social services or related field.
- Two years of experience providing direct service in the human service field or nursing or CM/Service Coordination.
- Strong written and verbal communication skills.
Nice To Haves
- Bilingual English/Spanish preferred.
Responsibilities
- Develops rapport with clients to engage them in improving their health and wellness.
- Administers standardized health and psychosocial risk screenings according to Health Home protocols and timeframes.
- Utilizes health screenings to identify interventions and develop a comprehensive care plan.
- Collaborates with members of the care team to identify needs and develop a plan to help clients achieve optimal health outcomes.
- Implements tasks outlined on the care plan and ensures follow up and continuity of care between client interactions.
- Regularly reviews and updates the care plan to correspond with services being provided.
- Documents all interventions and attempted contacts in the EHR in accordance with program standards.
- Works in collaboration with care providers to address Gaps in Care.
- Assesses domiciled client’s living conditions by conducting home visits.
- Works with family members and other collaterals of the client’s choice to facilitate planning and delivery of care.
- Provides comprehensive transitional care following hospitalization events in accordance with ACMH Critical Time Intervention (CTI) Protocols.
- Reviews new information and complex cases with PCP and multidisciplinary team and incorporates recommendations into the care plan.
- Facilitates care delivery by scheduling appointments, obtaining necessary information, and arranging transportation.
- Utilizes evidenced based practices, such as motivational interviewing, to empower clients to grow and attain goals.
- Embraces the team model by collaborating with members of the team and providing support as needed.
- Identifies community resources and makes referrals as needed.
- Supports client goals and serves as an advocate on client’s behalf.
- Administers CSD funds (Client Service Dollars) and submits required documentation.
- Regularly participates in team meetings and weekly clinical conference.
- Attends in-service training as requested.
- Performs duties as assigned by supervisor.
Benefits
- Generous benefits
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
