Care Navigator-In person-Fontana

Partners in Care Foundation In; Fontana (CA); On-site; USD 70,000 - 90,000; Full time

Job summary

Partners in Care Foundation is seeking a Care Navigator to support Kaiser Permanente Medi-Cal and dual eligible members. This field-based role partners with Emergency Department teams to improve care coordination, engage members, and connect them to ECM, CCM, social services, and community resources.

Responsibilities include real-time ED engagement, enrollment support, warm handoffs to Medicare/Medi-Cal teams, post-visit follow-ups, and ongoing workflow refinement in a fast-paced hospital

Qualifications

• Experience working with Medi-Cal, Medicare, Dual Eligible populations, or CalAIM programs
• Familiarity with hospital or Emergency Department operations
• Strong communication and patient engagement skills
• Ability to navigate complex systems and coordinate across multidisciplinary teams
• Experience with care coordination, community resource navigation, or social service linkage preferred
• Comfortable working in fast paced operational environments and adapting to evolving pilot workflows

Responsibilities

• Review real time ED census lists and identify eligible members for outreach
• Conduct in person member engagement within the Emergency Department
• Prioritize outreach based on utilization patterns, clinical complexity, and operational workflow needs
• Participate in ED huddles, operational meetings, and staff workflows as an integrated member of the KP Sacramento ED team
• Support enrollment into Enhanced Care Management (ECM), including coordination with authorization teams when needed
• Provide navigation support for members already enrolled in ECM or other care coordination programs (Community Supports, Community Health Workers, etc.)
• Connect members to appropriate Kaiser Permanente services including: Transitional Care Services (TCS), Complex Case Management (CCM), Social Work, Medical Financial Assistance (MFA)
• Conduct basic assessments to identify and/or support social and community resource needs
• Connect members to community-based organizations and external support programs when appropriate
• Connect dually eligible members to the appropriate Kaiser Permanente Medicare or Health Care Options (Medi-Cal) resources for conversion, alignment, or benefits related support
• Coordinate warm handoffs to internal Medicare / Medi-Cal support teams when appropriate
• Assist non-KP Medi-Cal members with connection back to their assigned Managed Care Plan for available services and supports
• Conduct post visit telephonic follow up with members after ED discharge
• Participate in ongoing workflow refinement and pilot operational development
• Collaborate with ED leadership and KP operational teams to improve member identification and engagement processes
• Document outreach and interventions according to pilot workflows and operational guidance
• TB test
• Immunizations required- COVID-19, Hepatitis B, Influenza, MMR (Measles, Mumps, and Rubella), Pertussis and Varicella (chickenpox)
• Field-based role with regular travel for home visits, community coordination, and partner meetings.
• Must have reliable transportation and ability to meet member safely in community settings.
• Must provide proof of auto liability insurance with limits required by the state of California and valid California drivers license.
• Must be able to perform essential job functions such as lifting 5-10 pounds.

Job description

The Care Navigator will be assisting Kaiser Permanente Medi-Cal members and dually eligible Medicare/Medi-Cal members. The role is designed to provide high touch navigation, engagement, and linkage support for members with complex medical, behavioral health, social, and utilization needs.

The Care Navigator will work closely with ED leadership, care coordination teams, social work, Transitional Care Services (TCS), Complex Case Management (CCM), Medicare teams, and community partners to help members navigate Kaiser Permanente services, CalAIM programs, and community-based resources.

The role focuses on real time member engagement in the ED setting, with the goal of improving care coordination, reducing avoidable ED utilization, and connecting members to the appropriate ongoing supports after discharge.

Core Responsibilities

Member Identification and Engagement

• Review real time ED census lists and identify eligible members for outreach
• Conduct in person member engagement within the Emergency Department
• Prioritize outreach based on utilization patterns, clinical complexity, and operational workflow needs
• Participate in ED huddles, operational meetings, and staff workflows as an integrated member of the KP Sacramento ED team

Care Navigation and Coordination

• Support enrollment into Enhanced Care Management (ECM), including coordination with authorization teams when needed
• Provide navigation support for members already enrolled in ECM or other care coordination programs (Community Supports, Community Health Workers, etc.)
• Connect members to appropriate Kaiser Permanente services including:
• Transitional Care Services (TCS)
• Complex Case Management (CCM)
• Social Work
• Medical Financial Assistance (MFA)
• Conduct basic assessments to identify and/or support social and community resource needs
• Connect members to community-based organizations and external support programs when appropriate

Benefits Support and Coordination

• Connect dually eligible members to the appropriate Kaiser Permanente Medicare or Health Care Options (Medi-Cal) resources for conversion, alignment, or benefits related support
• Coordinate warm handoffs to internal Medicare / Medi-Cal support teams when appropriate
• Assist non-KP Medi-Cal members with connection back to their assigned Managed Care Plan for available services and supports

Member Follow-Up and Operational Integration

• Conduct post visit telephonic follow up with members after ED discharge
• Participate in ongoing workflow refinement and pilot operational development
• Collaborate with ED leadership and KP operational teams to improve member identification and engagement processes
• Document outreach and interventions according to pilot workflows and operational guidance

Preferred Skills and Experience

• Experience working with Medi-Cal, Medicare, Dual Eligible populations, or CalAIM programs
• Familiarity with hospital or Emergency Department operations
• Strong communication and patient engagement skills
• Ability to navigate complex systems and coordinate across multidisciplinary teams
• Experience with care coordination, community resource navigation, or social service linkage preferred
• Comfortable working in fast paced operational environments and adapting to evolving pilot workflows

Other Requirements:

• TB test
• Immunizations required- COVID-19, Hepatitis B, Influenza, MMR (Measles, Mumps, and Rubella), Pertussis and Varicella (chickenpox)
• Field-based role with regular travel for home visits, community coordination, and partner meetings.
• Must have reliable transportation and ability to meet member safely in community settings.
• Must provide proof of auto liability insurance with limits required by the state of California and valid California drivers license.
• Must be able to perform essential job functions such as lifting 5-10 pounds.

Partners in Care Foundation is an equal opportunity employer. We are committed to complying with all federal, state, and local laws providing equal employment opportunities, and all other employment laws and regulations. It is our intent to maintain a work environment which is free of harassment, discrimination, or retaliation because of age, race (including hair texture and protective hairstyles, such as braids, locks, and twists), color, national origin, ancestry, religion, sex, sexual orientation, pregnancy (including childbirth, lactation/breastfeeding, and related medical conditions), physical or mental disability, genetic information (including testing and characteristics, as well as those of family members), veteran status, uniformed service member status, gender, gender identity, gender expression, transgender status, arrest or conviction record, domestic violence victim status, credit history, unemployment status, caregiver status, sexual and reproductive health decisions, salary history or any other status protected by federal, state, or local laws. All qualified applicants will receive consideration for employment and reasonable accommodations may be made to enable qualified individuals to perform the essential functions of the position.