Health Navigator

Integrated Services for Behavioral Health•Lancaster, OH

2d•Onsite

About The Position

Fairfield Community Health Center's (FCHC) goal is high-quality, better care for our patients. We have been recognized as a level 3 Patient-Centered Medical Home (PCMH) by the National Committee for Quality Assurance for all our family practice offices. PCMH means we offer a team approach, with the patient as the most important member of the team. FCHC offers improved access to care with extended hours, as well as same-day and next-day appointments. We work with specialists and hospitals to coordinate care to be sure that the entire healthcare team is working together to assure the best possible health for our patients. The Health Navigator role supports the organization's Patient-Centered Medical Home (PCMH) and HRSA Health Center Program requirements by ensuring coordinated, comprehensive, culturally responsive, and patient-centered care. This role advances access to care, continuity, population health management, community integration, quality improvement, and compliance with HRSA, NCQA, and other regulatory standards.

Requirements

High school diploma or GED required.
Minimum of one (1) year of experience in an ambulatory primary care, community health, or related healthcare office setting required
Ability to work in a team environment
Recognizes and participates in continuous quality improvement efforts for operational and workflow changes.
Demonstrates strong interpersonal, organizational, and customer service skills.
Demonstrates computer proficiency and ability to work with all Microsoft Office applications, incident tracking software, and other pertinent organizational software applications.
Demonstrates effective time management skills and ability to prioritize to meet operational demands.
Applies professionalism to all interactions with health center patients, employees, providers, contractors, and vendors.
Continually willing to learn, embrace change, and have a positive attitude.
Demonstrates understanding of the importance of patient confidentiality.
Ability to work independently and in a team environment.
Demonstrates dependability through good attendance and punctuality.
Demonstrates knowledge of Population Health Management, Patient-Centered Medical Home Concepts (PCMH), CPC, [JDS. And HEDIS.

Nice To Haves

Graduate of a Medical Assistant program, Licensed Practical Nurse (LPN), or equivalent clinical training preferred.
Certified Community Health Worker (CCHW) credential preferred, or willingness to obtain certification within an established timeframe.
Federally Qualified Health Center (FQHC) experience preferred.

Responsibilities

Facilitate timely access to primary and preventive care services
Coordinate referrals, transportation, hospital/ED discharges, and follow-up appointments
Provide enabling services to reduce barriers to care (e.g., navigation, scheduling support).
Support patients before, during, and after visits to improve engagement and continuity.
Assist in special outreach projects
Serve as a liaison between patients, families, providers, care teams, and community partners
Participate in daily huddles, interdisciplinary care team meetings, and panel reviews
Communicate identified care gaps, risks, and social barriers to providers and leadership.
Serve as a resource to providers and staff related to care coordination, population health workflows, and HRSA expectations
Promote shared decision-making, health literacy, and self-management using motivational interviewing
Provide ongoing follow-up, coaching, accountability, and advocacy
Manage patient panels, registries, and risk stratification using Azara DRVS
Review preventive services, labs, immunizations, utilization, and chronic disease measures
Conduct patient outreach directly or coordinate outreach based on registry and panel data
Monitor population-level trends and recommend interventions to improve outcomes and equity
Maintain current knowledge of community-based organizations and external resources
Link patients to social support including food access, housing resources, insurance assistance, and transportation
Participate in Quality Improvement (QI) activities aligned with PCMH and HRSA expectations
Assist with development, tracking, and implementation of QI goals and action plans
Track progress on preventive care, chronic disease outcomes, population health initiatives, and patient engagement
Provide education and support to staff and patients related to QI initiatives
Document all patient care and interactions (including phone calls and outreach) in the EMR per policy
Report to work as scheduled and perform duties as assigned
Serve as lead or support for special projects related to PCMH, HRSA, or population health
Participate in internal committees and QI workgroups as requested