Community Care Navigator

The Gathering Inn; Auburn (CA); On-site; USD 30,307,000 - 41,328,000; Full time

Job summary

The Gathering Inn seeks a Community Care Navigator embedded with Sutter Auburn Faith Hospital to bridge patients, care teams and shelter programs. You will manage a caseload of up to 15 clients, provide post-discharge follow-up, and connect individuals to housing, health and social services to reduce emergency visits.

Non-exempt, full-time hours Monday–Friday 9:00 am–5:30 pm with a 30-minute lunch; travel within the region may be required.

Qualifications

• Strong communication, organization and computer skills required.
• Ability to handle case management tasks and data entry into multiple systems.

Responsibilities

• Uphold the Mission, Vision and Values of The Gathering Inn and maintain a guest-first mentality.
• Meet with patients in hospital or ER to assess issues and needs.
• Identify services and connect with the healthcare team.
• Evaluate patients for Care Navigation eligibility and complete intakes/treatment plans.
• Facilitate case management to meet stabilization goals and outcomes.
• Participate in case conferences to discuss client care planning.
• Collaborate with service providers to assist members.
• Enter data and generate reports in Epic, NextGen and HMIS.
• Protect patient data per HIPAA and maintain confidentiality.
• Advocate for clients and coordinate care with medical and mental health professionals.
• Assess functional status and refer for appropriate care.

Skills

Communication skills

Computer skills

Organization skills

Education

High school diploma or equivalent

Job description

Description

POSITION: Community Care Navigator

REPORTS TO: Director of Medical Respite Program

HOURS: Full time, Monday – Friday 9 AM – 5:30 PM; 30-minute lunch

POSITION SUMMARY:

The Community Care Navigator is embedded in Sutter Auburn Faith Hospital and acts as a liaison between patients, hospital care team and TGI with the goal of reducing emergency use and providing stable recovery services for people experiencing homelessness, and/or those who frequent the hospital for complex medical and social needs. This position compliments the hospital-based Care Coordination department to establish care connections and transition plans for patients, including both in-patient and emergency department . The Community Care Navigator will facilitate warm hand-offs to TGI shelter and ICP where client will receive case management services through those programs. In addition, the Community Care Navigator will provide unhoused clients with case management for a caseload of up to 15 clients at one time, and provide follow-up services for up to 6 months. Upon discharge, continued Case Management services and medical respite will extend support to help reduce unnecessary hospital readmission.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Uphold the Mission, Vision and Values of The Gathering Inn and maintain a guest-first mentality at all times.
• Meet with patients in hospital or emergency room to assess issues, needs.
• Identify services needed and willingness to connect. Collaborate with dedicated healthcare team.
• Evaluate patients for appropriateness for Care Navigation program, complete intakes and treatment plans accordingly.
• Facilitate case management services to support successful outcomes and meet stabilization goals.
• Participate in case conferences with multi-disciplinary team to discuss client care planning and progression.
• Collaborate with local service providers, outreach workers, case managers and multiple agencies to facilitate services for members.
• Construct comprehensive reports, efficient in data entry into databases: Epic, Nextgen and HMIS.
• Protect patient data in alignment with HIPAA privacy protocols, maintain high level awareness of ethics.
• Advocate for clients, consult with medical and mental health professionals, coordinate care and navigate resources available.
• Determine functional status, activity, acuity and self-management levels to make proper care referrals.
• Perform audits of objectives and case progression for case management team.
• Teach clients coping skills and functional living skills, facilitate groups for interactive learning and sharing with multiple topics focused on SUD issues, with life skills identification and development.
• Monitor behavior in individual and group sessions and intervene when necessary. Maintain accurate and descriptive progress notes.
• Provide resources for addiction, recovery, relapse prevention, social issues and mental health problems.
• Refer clients to programs and community agencies for the needs identified outside of agency provision, and assist with enrollment including paperwork, registration, etc. This is including but not limited to the following tasks:
• Obtaining new mobile phone
• Shelter intake
• Bill paying
• Enhanced Care Management
• In-home supportive services (IHSS)
• Social security benefits
• VA services
• Insurance plan enrollment
• Primary care providers
• Observe signs and symptoms, interview and directly assess clients to diagnose issues and determine optimal interventions and risk level.
• Liaise with family members to discuss progress and develop ongoing strategies for support in clients’ goals.
• Identify personal crisis elements and assist in developing solutions with the client.

POSITION EXPECTATIONS:

• Be punctual. No more than one late occurrence per quarter. If you know you are going to be late, you must contact your Supervisor at least one hour in advance.
• Complete paperwork, HMIS data entry, and tasks in a timely and consistent manner, including all reports, etc. You should be able to regularly prioritize your daily tasks independently but be willing to ask for guidance from your Supervisor if conflicts arise.
• Complete work accurately – proofread all documents you are responsible to create or distribute.
• Become familiar with office systems so that you can locate documents and information at any given time.
• Keep organized (desk, files, etc.)
• Use good judgment and discretion in all aspects of this position. Make ethical, non-biased and well thought-out decisions.
• Communicate regularly with Management and co-workers on all pertinent issues. Must be able to regularly interface with Emergency Department and Care Coordination staff at the hospital.
• Assist others in a compassionate manner without ethnic or social prejudices. Be tactful and mindful of issues & challenges unique to homelessness, substance abuse and persons with physical and mental disabilities.
• Be able to perform duties independently and also as part of a team.
• Demonstrate computer proficiency for all programs used by the organization.

SUPERVISORY RESPONSIBILITIES:

None at this time.

Requirements

QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals to perform the essential functions.

EDUCATION and/or EXPERIENCE:

High school diploma or equivalent. Specific knowledge and experience with Twelve Step philosophy, addiction and recovery, and dysfunctional family dynamics is preferred.

WORKING HOURS:

This is a non-exempt position. Working hours are from 9 am – 5:30 pm with a 30-minute lunch break. However, overtime may be required and will be paid in accordance with non-exempt position requirements. Any overtime worked should be approved in advance by the Supervisor.

TRAVEL:

Travel within the greater Placer County region will be required on a regular basis. Therefore, a personal vehicle in good working condition and insured according to Organization policy will be required to fulfill the duties of this position. Mileage driven will be reimbursed at standard rates.

DRESS:

Neat and casually professional.

TRAINING:

Increased value to the Organization may require additional schooling or other types of training depending on individual goals.

LANGUAGE SKILLS:

Ability to read and interpret documents, to write reports and correspondence, and to speak effectively with groups of people including other employees, Board members, potential donors, etc.

MATHEMATICAL SKILLS:

Ability to perform basic mathematical calculations (add, subtract, multiply and divide).

REASONING ABILITY:

Ability to apply common sense understanding to carry out instructions furnished in written, oral or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

CRITICAL TECHNICAL REQUIREMENTS:

This position requires strong communication, organization and computer skills.

CRITICAL BEHAVORIAL REQUIREMENTS:

This position requires a commitment to carrying out the Mission, Vision and Values of the Organization. It is also essential to take responsibility, be trustworthy and to carry a high level of confidentiality. Flexibility, good judgment and an ethical and honest outlook are also essential behavioral qualities.

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.? while performing the duties of this job, the employee is regularly required to sit; use hands and fingers, to handle objects, paper, etc.? The employee is occasionally required to stand, walk, reach with hands and arms, climb or balance, and stoop, kneel and crouch. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this position include close vision, distance vision, depth perception and ability to adjust focus. The employee regularly needs to talk and hear.?

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Noise level in the work environment is usually moderate.

The Gathering Inn is an Equal Opportunity Employer.

The Gathering Inn maintains a drug-free workplace.