Social Care Navigator

Virginia Garcia Memorial Health Center•Cornelius, OR

About The Position

The Social Care Navigator functions as an integral part of the BHMH Services Department's Primary Care integration to assess and address patient's needs as related to their resilience/self-determination, ability to access outpatient services and social determinants of health. This individual provides skills training and case management services and links patients to needed community resources through their work on medical and BHMH teams to coordinate services and care that address their medical, mental health and/or other psychosocial needs. They also work 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 hospital and Emergency Department services. This position may supervise students in disciplines appropriate to the Navigator's educational background and qualifications.

Requirements

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.
High level of skill in interpersonal relations and problems solving.
High energy and self-directed individual 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 of 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.
Bachelor'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.
Meet criteria for QMHA in the state of Oregon (requires a bachelor's degree in behavioral health or alternatively a combination of three years of relevant education and occupational experience).
Current CPR certification.

Nice To Haves

Bilingual/bicultural proficiency preferred.
Training in Motivational Interviewing, skills training and case management preferred.
Experience with group facilitation.
Prior EMR experience preferred.

Responsibilities

Function as an integral part of the BHMH 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.
Assess patients' social determinants of health and health literacy, utilizing screening tools and questionnaires to assess the patient's living situation, health literacy, safety, cognitive abilities or status, history of or current substance misuse, physical, mental or sexual abuse, intimate partner violence, and mental health needs.
Gather and maintain 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, in order 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.
Participate with the team in developing a comprehensive care plan.
Communicate with the primary care team, documenting all contacts with patients in the EHR (EPIC) in a timely manner and communicating 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 BHMH to outreach patients with complex health and/or psychosocial needs and those who are high utilizers of hospital and Emergency Department services in order 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.
May supervise students in disciplines appropriate to the Navigator's educational background and qualifications.
Attend regular trainings 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).