Street Medicine-Scope Care Navigator

Akido•Ontario, CA

5d•$21 - $29

About The Position

The Street Medicine-Scope Care Navigator is a hybrid social support role and a first point of contact for patients by phone and, as needed, in encampments, shelters, and other community settings. The navigator supports people experiencing homelessness through Akido’s Street Medicine program and covers Scope inbound and outbound queues by conducting pre-visit assessments. The role gathers health and social histories, screens for needs, and connects patients with appropriate care and community resources. The navigator spends most of the day on the phone in a high-volume, call center–style environment. They use structured health, psychosocial, and risk/needs assessments to discuss medical history, chronic conditions, medications, behavioral health, substance use, housing status, and social determinants of health. They build rapport with a vulnerable population using a trauma-informed, non-judgmental approach, recognize urgent clinical needs, and escalate them to clinical staff. The role follows defined scripts, workflows, escalation protocols, and productivity, response-time, and quality standards. Working with community health workers, street medicine providers, medical assistants, and case managers, the navigator helps connect patients to resources and maintain engagement through warm hand-offs and follow-up outreach. They document contacts and outcomes in telephony and call management systems and maintain accurate, real-time, HIPAA-compliant EHR documentation. They also track outcomes and follow-up status on program dashboards, participate in call monitoring, QA reviews, and coaching, and perform other administrative tasks that support care coordination and healthcare team operations.

Requirements

High school diploma or equivalent required.
At least 2 years of experience in case management, social work, care coordination, call center operations, community outreach, or a related patient-facing healthcare or social services role.
Lived experience or significant experience working with underserved populations.
Familiarity with community resources, public health programs, and social services in the area.
Working knowledge of basic health assessment concepts, including health history, common chronic conditions, and medication basics, sufficient to conduct a structured health intake.
Familiarity with social determinants of health and community resource navigation, including housing, benefits, behavioral health, and substance use services.
Strong interpersonal and communication skills, including the ability to handle complex situations effectively.
Strong phone-based communication skills, including the ability to build rapport, de-escalate, and gather sensitive information with empathy and professionalism.
Comfort working in a high-volume, metrics-driven phone environment.
Comfort working with individuals experiencing homelessness, trauma, mental illness, and/or substance use disorders.
Excellent documentation skills and comfort working in an EHR or care management system.
Passion for community health, patient support, and improving access to healthcare services.
Ability to sit and/or stand for prolonged periods of time.
Ability to communicate with others to exchange information.
Ability to use and/or type on a laptop or keyboard.
Ability to wear a headset and speak by phone for extended periods.

Nice To Haves

Associate or bachelor’s degree.
EMT, CPXP, patient experience, or similar health systems or clinical support credential.
Bilingual in Spanish or other languages common in the service area.
Prior experience with Street Medicine, homeless health services, ECM, or similar safety-net settings.
Prior call center, contact center, or telephonic care management experience in a healthcare setting.
Experience with motivational interviewing or trauma-informed care approaches.
Direct outreach experience in encampments, shelters, drop-in centers, or other community settings.

Responsibilities

Conduct telephonic intakes for patients experiencing homelessness in the Street Medicine program and pre-visit assessments for Scope patients.
Handle inbound and outbound queues in a high-volume, call center–style environment.
Use standardized health, psychosocial, and risk/needs assessments to gather medical and social history, including chronic conditions, medications, behavioral health, substance use, housing status, and social determinants of health.
Build rapport and engage patients using a trauma-informed, non-judgmental approach; adapt tone and pacing, de-escalate when needed, and gather sensitive information professionally.
Recognize urgent clinical needs and promptly escalate them to clinical staff.
Follow call scripts, workflows, and escalation protocols while meeting productivity, response-time, and quality standards.
Log contact attempts and outcomes in telephony and call management systems, including soft phone platforms and disposition coding.
Work alongside community health workers to connect patients with community resources and provide warm hand-offs and follow-up outreach.
Follow up with providers on escalated calls as needed to confirm connections and protocol adherence.
Coordinate with street medicine providers, medical assistants, and case managers.
Maintain accurate, real-time, HIPAA-compliant documentation in the EHR.
Track outcomes and follow-up status on program dashboards to support reporting and quality improvement.
Participate in call monitoring, QA reviews, and coaching.
Perform other duties as assigned, including administrative tasks supporting care coordination and healthcare team operations.