Community Care Navigator-Population Health

Asheville, NC - USA

Monthly Salary: Not Disclosed

Posted on: 21 hours ago

Vacancies: 1 Vacancy

Job Summary

JOB SUMMARY:

CareNavigationwillbe part ofMAHECs PopulationHealthAdministrationembedded inprimary careteamsto ensure that patients receive the resources and services they need. The Care Navigatorpositionsworkwiththeclinicalteams behavioralhealthand community providersto coordinate care andmeet performancegoals.The rolesprimaryresponsibility isassisting patientswith needed support services to achieve personal goals and optimal health.

SPECIFICRESPONSIBILITIES:

Engages and interacts with patients and/or family members to obtain and documentaccuratehistories build a trusting relationship and implementperson-centered care plan.

Works to develop a strong relationship withidentifiedpatientsandfacilitatespatient engagement during in person visits groupvisitsand virtually.

Uses motivational interviewing to gather pertinent clinical and psychosocial information from the patient and his/her friends and family asappropriateand coaching and support to achieve self-management goals.

Proactivelyidentifiespotential barriers to care plan initiate interventions withProviders(s)Nursing care managers clinical social workers and other caregivers to include alternative options to meet desired goals.

Communicates effectively withappropriate caregiversto achieve targeted outcomes.

Documents activities service plans and results in an effective mannerwith EHR and care management platform

Refers patients and their families who need assistance to the appropriate educational resources regarding health care delivery and reimbursement prescription drug programs health and wellness programs long term care insurance asset and legal management government programs community agencies public and private organizations housing options and other services as appropriate.

Providespatient self-management support for priority chronic conditions or pregnancy and wellchildcare.

Collaborates with practiceand organizationalleadership to define workflows that meet contracted goals and requirements for screening qualityoutreachand care coordinationto meet the goals ofcontracted requirements.

Utilizes a Team Based Care approach to ensure patients are appropriately screened for depression and social determinants of health.

Supports follow up on positive screening.

Usesdocumentation tools to support thepatientgoalsdocumentation of the careplanand closed loop referrals forhealth-relatedsocial needs.

Utilizes available tools toidentifyclinical gaps in care and communicate with the clinical team to support closing quality gaps and evaluate suspect conditions.

Ensures communication of the patient care coordination plan to members of the Primary Care team.

Serves as a liaison between care teams and community groups and foster and develop relationships with key contacts in those groups.

Collaborates withleadershiptomaintainpartnerships with local community-based agencies and programsandsupportthe success of the team in navigating these patient care needs.

Works with leadership to providetraining on theworkflows anddocumentationof health related social need toassure a plan for success in using the system to accept and respond to referrals.

Supports obtaining and developing education for clinicalteamto understand community partners in the counties served.

SupportsClinical ProvidersCare Managers andBehavioral Health Consultantsin coordinating community providers/services.

Utilizes a team-based approach to manage andassistin the care coordination process.

Seekstoeliminateconfusion and duplication in services andsupportsquality value- orientedcare in coordination with patients caregivers providers andappropriate communitycare partners.

Collaborates tomaintaina resource databasespecific topatientslocal needs.

This role description is a general description of the essential job functions.It is not intended to describe all the dutiesthe Care Navigatormay perform.

KEY COMPETENCIES:

Communication Skills

Effectively and respectably communicate with other individuals whether it be a colleague patient or patients family member and appropriatelyenumerateinformation in a manner easily understood by all parties. We do this to foster a culture of understanding between all parties especially in complex anddifficult situations toultimately providethe best care possibletoour patients and their families.

Decision Making

Ability to make the mostappropriate decisionin a givensituation and thentakingthe next steps to ensureappropriateandtimelycompletion. Thisrequires conflict resolution skills critical thinking skills confidencein your ability to make the right decision in most situations. This also includesabilityto prioritize your workday appropriately to ensure the most important tasks are completed on time.

HealthCare Knowledge

Having the drive to keep yourself abreast and up to date on the new breakthroughs in your area of expertise and communicating them to the rest of the team as appropriate.This also includes keeping up with your licensure and yearly training requirements within yourareaexpertisealong with MAHECs organizational training. Finally the ability to apply the depth of knowledgemaintainedand gained through this process in real life scenarios asappropriate.

Interpersonal Skills

Showing the ability to meetdifficult situationswith grace professionalism and understanding. Within your area of expertise showing respect and showing empathy where appropriate with your colleagues patients and their familyat all times even whenitsmost difficult to do so. This is done in part by effective listening being your authentic self showing responsibility and dependability and being patient with others.

Organizational Values

Adherence to MAHECs founding principles and incorporating them every day. This includes among others having integrity and accountability reverence for other cultures andequitablepracticesabilityto manage change and displaying a clear understanding of organizational dynamics. Doing these things creates a culture where people want to dothebest for each other and gives personal ownership towards the goal of helping people in their time of need.

Problem Solving

Having an analytical mind and ability to work autonomously to solve complex problems that may arise. The wherewithal to think logically through a difficult problem and come toan appropriate resolutionfor a given issue. This helps to drive continuous improvement by thinkingthroughwhere we can improve in a novel way. Measures success by understanding where we are currently and where we want to go and then applying thosenew ideasto affect positive change.

SPECIFIED SKILLS

Computerproficiency electronic health recordor care management platformexperience preferred.

Ability to flourish in a team system that supports equity and inclusion.

Excellent skills in Microsoft Office including Word Excel PowerPoint and database applications.

PREFERRED SKILLS:

Entry-levelproficiencyin another language such as SpanishRussianor Ukrainian preferred.

PHYSICAL DEMANDS:

Not Applicable

SUPERVISORYRESPONSIBILITIES:

Not Applicable

EDUCATION OR EXPERIENCE:

Required

Associatesdegreeinhealthrelatedfieldtwo years of undergraduate educationin the social sciencesorcertification or license in a related field of study

Preferred

Bachelorsdegree in social workor otherSocial Science Community Health Worker Certified Health Education Specialist (CHES)or Peer Support Specialist. 3 years of experience in health care.

SCHEDULE:

Monday Friday 8:00 am to 5:00 pm (or flexed to best meet the needs of the clients and/or the Division);40 hoursper workweek; weekend holiday or evening coverage is occasionally. Work hours will need to be flexiblein order torespond to special work assignments or evening activities as requested by the team leader.

POSITION COMPENSATION:

$51800 full time full benefits available

At MAHEC we strive to equip all team members with Total Rewards (pay benefits) to honor their service support their health manage their financial security build their career and thrive.

All MAHEC employees and learners will be required to receive the Flu vaccine or have an approved exemption.

MAHEC Talent Management is located at 121 Hendersonville Road Asheville NC 28803. Equal Opportunity Employer.

MAHEC is a qualifying employer for the Public Service Loan Forgiveness (PSLF) Program. Employees who meet federal requirements may be eligible to have remaining student loan balances forgiven after 10 years of qualifying payments while working full-time at MAHEC.

If you are interested in this role and you have related experience and qualifications we encourage you to apply or reach out to for support in your job search process. You could be the talent we are seeking for this or other opportunities.

JOB SUMMARY:CareNavigationwillbe part ofMAHECs PopulationHealthAdministrationembedded inprimary careteamsto ensure that patients receive the resources and services they need. The Care Navigatorpositionsworkwiththeclinicalteams behavioralhealthand community providersto coordinate care andmeet perform...