Community Care Navigator - Asheville, NC

Mountain Area Health Education Center; Biltmore (FL); On-site; USD 47,000 - 57,000; Full time

Job summary

Mountain Area Health Education Center (MAHEC) in Asheville, NC seeks a Care Navigator to join its Population Health Administration. You will coordinate patient care across clinical teams and community providers, focusing on self-management support and addressing social determinants of health.

The role emphasizes team-based care, motivational interviewing, and effective use of care management tools to close gaps in care and meet contracted goals.

Qualifications

• Associate's degree in health-related field, or certification/license in a related field.
• Two years of undergraduate education in the social sciences.
• Bachelor's degree in social work or related field preferred.
• CHES or Peer Support Specialist preferred.

Responsibilities

• Engages with patients/families to obtain histories and document a person-centered care plan.
• Builds trust and engages patients during in-person, group, and virtual visits.
• Uses motivational interviewing to gather information and supports self-management goals.
• Identifies barriers and coordinates interventions with Providers and care team.
• Refers patients to educational resources regarding health care delivery and programs.
• Documents care plans, activities, and results in EHR and management platforms.
• Coordinates with community providers and resources to address social needs.

Skills

Computer skills

Spanish language

Education

Associate's degree in health-related field

Undergraduate coursework in social sciences (2 years)

Bachelor's degree in social work or related field

CHES or Peer Support Specialist

Tools

Microsoft Office

Care management platform

Job description

JOB SUMMARY

Care Navigation will be part of MAHEC's Population Health Administration embedded in primary care teams to ensure that patients receive the resources and services they need. The Care Navigator positions work with the clinical teams, behavioral health and community providers, to coordinate care and meet performance goals. The role's primary responsibility is assisting patients with needed support services to achieve personal goals and optimal health.

SPECIFIC RESPONSIBILITIES

Engages and interacts with patients and/or family members to obtain and document accurate histories, builds a trusting relationship, and implements a person-centered care plan. Works to develop a strong relationship with identified patients and facilitates patient engagement during in person visits, group visits and virtually. Uses motivational interviewing to gather pertinent clinical and psychosocial information from the patient and his/her friends and family as appropriate and coaching and support to achieve self-management goals. Proactively identifies potential barriers to care plan, initiate interventions with Providers(s), Nursing care managers, clinical social workers, and other caregivers to include alternative options to meet desired goals. Communicates effectively with appropriate caregivers to achieve targeted outcomes. Documents activities, service plans, and results in an effective manner with 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. Provides patient self-management support for priority chronic conditions or pregnancy and well childcare. Collaborates with practice and organizational leadership to define workflows that meet contracted goals and requirements for screening, quality, outreach and care coordination to meet the goals of contracted 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. Uses documentation tools to support the patient goals, documentation of the care plan and closed loop referrals for health-related social needs. Utilizes available tools to identify clinical 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 with leadership to maintain partnerships with local community-based agencies and programs and support the success of the team in navigating these patient care needs. Works with leadership to provide training on the workflows and documentation of health related social need to assure a plan for success in using the system to accept and respond to referrals. Supports obtaining and developing education for clinical team to understand community partners in the counties served. Supports Clinical Providers, Care Managers and Behavioral Health Consultants in coordinating community providers/services. Utilizes a "team-based approach" to manage and assist in the care coordination process. Seeks to eliminate confusion and duplication in services and supports quality, value- oriented care in coordination with patients, caregivers, providers, and appropriate community care partners. Collaborates to maintain a resource database specific to patient's local needs.

KEY COMPETENCIES

Communication Skills: Effectively and respectably communicate with other individuals, whether it be a colleague, patient, or patient's family member and appropriately enumerate information in a manner easily understood by all parties. We do this to foster a culture of understanding between all parties, especially in complex and difficult situations, to ultimately provide the best care possible to our patients and their families.

Decision Making: Ability to make the most appropriate decision in a given situation and then taking the next steps to ensure appropriate and timely completion. This requires conflict resolution skills, critical thinking skills, confidence in your ability to make the right decision in most situations. This also includes ability to 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 your area expertise along with MAHEC's organizational training. Finally, the ability to apply the depth of knowledge maintained and gained through this process in real life scenarios as appropriate.

Interpersonal Skills: Showing the ability to meet difficult situations with grace, professionalism, and understanding. Within your area of expertise, showing respect and showing empathy where appropriate with your colleagues, patients, and their family at all times, even when its most 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 MAHEC's founding principles and incorporating them every day. This includes, among others, having integrity and accountability, reverence for other cultures and equitable practices, ability to manage change, and displaying a clear understanding of organizational dynamics. Doing these things creates a culture where people want to do the best 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 to an appropriate resolution for a given issue. This helps to drive continuous improvement by thinking through where we can improve in a novel way. Measures success by understanding where we are currently and where we want to go and then applying those new ideas to affect positive change.

SPECIFIED SKILLS

Computer: Excellent skills in Microsoft Office including Word, Excel, PowerPoint, and database applications required. Care management platform experience preferred.

Foreign Language: Spanish speaking skills preferred.

EDUCATION AND EXPERIENCE

MINIMUM QUALIFICATIONS: Associate's degree in health-related field, two years of undergraduate education in the social sciences or certification or license in a related field of study.

PREFERRED QUALIFICATIONS: Bachelor's degree in social work or other Social Science, Community Health Worker, Certified Health Education Specialist (CHES) or Peer Support Specialist. Three years of experience in health care.

SCHEDULE

Regular attendance on-site is an essential function of this position. Typical business hours are Monday – Friday, 8:00 am to 5:00 pm (or flexed to best meet the needs of the clients and/or the Division); 40 hours per workweek; weekend, holiday, or evening coverage is occasionally required. Work hours will need to be flexible in order to respond to special work assignments, or evening activities, as requested by the team leader.

COMPENSATION

$51,800 annually, exempt + MAHEC Total Rewards Package.

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. 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.

ELIGIBILITY & COMPLIANCE

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

MAHEC does not provide employment-based US visa sponsorship, now or in the future.

All new employees must provide valid, original I-9 documents on their first day of work.

ABOUT US

MAHEC Talent Management is located at 121 Hendersonville Road, Asheville, NC 28803.

Equal Opportunity Employer.

Thank you for your interest in employment with Mountain Area Health Education Center in Asheville, NC, where we are committed to improving health in western North Carolina through innovative health professions education and compassionate healthcare. MAHEC was established in 1974 to improve training and retention of healthcare professionals across our region. We are dedicated to excellence in clinical care, health professions education, and innovative practices that can be replicated nationally. The largest of the nine state AHEC's, MAHEC serves NC's 16 westernmost counties to address national and state concerns with the supply, retention, and quality of health professionals especially in rural areas.