Social Care Navigator II

Virginia Garcia Memorial Health Center•Cornelius, OR

15h•$81,708•Hybrid

About The Position

The Social Care Navigator II functions as an integral part of the Integrated Behavioral Health Department’s Primary Care integration providing consultation, conducting assessment and delivering individual counseling to better assess and address patient’s needs as related to their resilience/self-determination, their ability to access outpatient services, and social determinations of health. This individual supports our population health initiatives through a behavioral health lens. This individual also provides skills training and case management services to patients that could benefit from community resources and care coordination that addresses their medical, mental health, and/or other psychosocial needs. The SCN II will collaborate with the Primary Care Teams to outreach and work with complex health and/or psychosocial needs of patients and those who are high utilizers of hospitals and Emergency department services. This position may supervise students in disciplines appropriate to the SCN II’s educational background and qualifications.

Requirements

Bilingual/bicultural proficiency preferred.
Desire to work with underserved communities.
Desire to work with complex patients, including those who may be struggling with mental health and/or substance use.
Cultural competency.
Knowledge of methods of behavioral medicine and evidence-based treatments for medical, mental and behavioral health conditions.
Desire to provide short, goal centered counseling to eligible individuals.
Knowledge of how to address crisis situations.
High level of skill in interpersonal relations and problem solving.
High energy and self-directed individuals with excellent interpersonal, problem solving, organizational, and computer skills.
Ability to travel to clinics, home visits, and agency visits, etc. in a reliable, confidential, and timely manner.
Ability to take initiative to proactively organize and manage the responsibilities of the job.
High degree in integrity and professionalism.
Good working knowledge of available social service resources or skills to acquire knowledge and information expeditiously.
Ability to work in challenging environments in the community at large and in patients’ homes.
Ability to work as an integral part of a high functioning team.
Highly proficient with Microsoft Office applications (Word, Excel, PowerPoint, Outlook).
Excellent Customer Service skills.
Commitment and alignment to Virginia Garcia’s mission, vision, and values.
Valid driver’s license, reliable transportation, safe driving record, and insurance coverage required.
Master’s degree in a relevant field or minimum four years of college education, preferably in psychology, social work, human services or health-related field required, or equivalent combination of education and experience.
Registered or will register with the Board of licensees as an associate with a CSWA or LPC-A.
Meet criteria for QMHP in the state of Oregon.
Knowledge of therapeutic modalities and approaches
Demonstrated ability to conduct an assessment including identifying precipitating events, gathering histories of mental and health, alcohol and other drug use, past mental health services, and criminal justice contacts, assessing family, social and work relationships and conducting a mental status examination, complete a DSM diagnosis; write and supervise the implementation of an Individual Services and Support Plan and provide individual, family, and/or group therapy within the scope of their training.
Current CPR certification.
Experience with group facilitation.

Nice To Haves

Prior EMR experience preferred.

Responsibilities

Function as an integral part of the Integrated Behavioral Health Team attending huddles, team meetings and coordinating services with team members for complex patients.
May work with primary care medical teams, attending huddles and team meetings and connecting with team members as needed to assess patient’s needs and connect them to resources in the medical and social services community.
Provide targeted evidence-based assessment and evaluations, which may include brief neuropsychological screens, diagnostic interviews, and impressions and functional status focused on the presenting problem. This can include assessing and justifying a complete DSM mental health diagnosis.
Develop treatment plans and provide ongoing outpatient mental health therapy. Conducts crisis interventions and safety planning.
Will provide a varied mix of mental health services and health and behavior interventions, depending on credentials and site.
Complete concise documentation in the electronic healthcare system of care and recommendations in the patient’s medical record within 24 hours of seeing the patient.
Provides case management and gathers and maintains information, resources and accessible services of community agencies, local and state organizations, acting as a liaison with outside agencies.
Build a supportive relationship with patients to improve patients’ utilization of necessary and appropriate primary care, mental health, and social services, to improve the patients’ health status and health outcomes.
Use motivational interviewing to assess and positively affect the patient’s level of engagement in their care and confidence in their ability to carry out a self-management plan.
Communicate with the primary care team, documenting all contacts with patients in the EHR (EPIC) in a timely manner and communicate in person or by phone as needed.
Provide culturally and clinically appropriate medical and mental health education and information to patients and coaches patients in making healthy lifestyle changes.
Act as the patient’s advocate and health navigator, assisting them in understanding the most appropriate use of health care resources.
Work with the Primary Care Teams and Integrated Behavioral Health to outreach patients with complex health and/or psychosocial needs and those who are high utilizers of hospital and Emergency Department services to remove barriers to care.
Provide work in the community with patients including home or hospital/ED visits and/or patient accompaniments to medical or social service appointments.
May facilitate, coordinate and organize group education or group provider visits, if approved by the supervisor and in consultation with the site management team.
Meets performance standards for productivity, documentation (including progress notes, assessments, treatment plans and authorization requests) proficiency in clinical model and evidence-based practices, quality of care (including engagement and retention) and teamwork as defined in the Performance Review
May supervise students in disciplines appropriate to the SCN II’s educational background and qualifications.
Attend weekly supervision (internal or external) as required by licensure regulation.
Attend regular training as required.
Perform other duties as assigned.
Handle protected health information in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).