Community Health Patient Navigator

Memorial Hermann; Portland (OR); Sur place; USD 55 000 - 75 000; Plein temps

Résumé du poste

Memorial Hermann in the United States is seeking a Patient Care Navigator to provide in-person support in clinical settings, focusing on NMDOH, motivatational interviewing, and helping patients transition to stable care in the community. The role collaborates with social workers, case managers, and clinical staff to align support plans and connect patients to resources upon discharge.

You will document encounters in EPIC, track NMDOH indicators, and participate in efforts to reduce ER visits and

Qualifications

• Education: High school or GED; Associate's degree preferred.
• CHW certifications/licensing per TDSHS required.
• Spanish bilingual strongly preferred.
• Minimum three years in healthcare/hospital settings, especially with underserved or high-risk populations.
• Experience providing in-person bedside support.
• Proficiency with EPIC or similar EHR systems.
• Strong organizational and time management skills.
• Ability to work in a multidisciplinary team.

Responsabilités

• Conduct NMDOH screenings and document risk levels for housing, food, utilities, etc.
• Use motivational interviewing to engage patients and explore readiness for action.
• Collaborate with social workers and case managers to develop discharge plans addressing clinical and non-clinical factors.
• Refer patients to internal and external resources ensuring alignment with needs and eligibility.
• Document interactions, screenings, and referrals in Epic for tracking and follow-up.
• Identify trends and service gaps and escalate insights to leadership for program improvements.
• Participate in community-based activities related to NMDOH and patient navigation.

Connaissances

Motivational Interviewing

Spanish Bilingual

Communication Skills

Time Management

Team Collaboration

Formation

High School Diploma

Associate's Degree

CHW Certifications

CHW Instructor

CHW-E

CHW-T

CPN Certification

CHW Certifications (TDSHS)

Outils

EPIC

Microsoft Office

Description du poste

At Memorial Hermann, we pursue a common goal of delivering high quality, efficient care while creating exceptional experiences for every member of our community. When we say every member of our community, that includes our employees. We know that when our employees feel cared for, heard and valued, they are inspired to create moments that exceed expectations, while prioritizing safety, compassion, personalization and efficiency. If you want to advance your career and contribute to our vision of creating healthier communities, now and for generations to come, we want you to be a part of our team.

Job Summary

The Patient Care Navigator is responsible for providing in-person support to patients in clinical settings such as the emergency departments, inpatient units or outpatient clinic settings. This role focuses on identifying and addressing non-medical drivers of health (NMDOH), supporting behavior change through advanced experience in motivational interviewing, and helping patients transition to stable care in the community. The Patient Navigator rounds, engages patients with compassion and humility, and collaborates closely with care coordination teams such as social workers, case managers, and clinical staff, to align support plans and facilitate connections to internal and external resources upon discharge. This role plays a key part in reducing avoidable emergency room (ER) utilization and preventable readmissions among vulnerable patients with chronic or ambulatory care sensitive conditions. The Patient Navigator is responsible for timely documentation in EPIC, and identifying patterns or gaps impacting patients, which connects to broader system goals within the Community Health Network. This position typically reports to a Manager within the Community Health Network's ER Navigation Program and/or Inpatient Navigation Program.

Minimum Qualifications

• Education: High school or GED required. Associate's degree in related field preferred.
• Licenses/Certifications (required): Community Health Worker (CHW) by the Texas Department of State Health Services (TDSHS)
• Community Health Worker - Instructor (CHW-I) by the Texas Department of State Health Services (TDSHS)
• Community Health Worker -Experience (CHW-E) by the Texas Department of State Health Services (TDSHS)
• Community Health Worker - Training (CHW-T) by the Texas Department of State Health Services (TDSHS)
• Preferred Licenses/Certifications: Certified Patient Navigator (CPN) by the Patient-Centered Education & Research Institute and Academy of Oncology Nurse & Patient Navigators (AONN+)
• Motivational Interviewing Certificate or training completion by the Texas Department of State Health Services (TDSHS) or Texas Health and Human Services (HHSC)
• Experience / Knowledge / Skills: Minimum three (3) experience in healthcare or hospital settings, especially with underserved or high-risk populations, preferred.
• Experience providing in-person support to patients at the bedside in hospital or clinical settings.
• Effective oral and written communication skills, with the ability to build trust and rapport across diverse populations.
• Bilingual (Spanish) strongly preferred.
• EPIC or other EHR experience preferred; must be comfortable navigating digital documentation and referral systems.
• Strong knowledge of NMDOH and an understanding of community resources.
• Strong organizational and time management skills, with the ability to manage multiple referrals and follow-ups.
• Ability to work collaboratively as part of a multidisciplinary team while maintaining empathy, discretion, and professionalism.
• Experience using Microsoft Suite (Word, Excel).

Principal Accountabilities

• Conducts screenings to identify NMDOH and accurately documents patients' risk levels for each domain (e.g. housing, food, utilities) within the designated electronic medical record system (e.g. EPIC) and to determine eligibility for public assistance and community support programs.
• Uses advanced motivational interviewing techniques to engage patients in behavior change, build trust, and explore readiness for action.
• Collaborates with care coordination teams (e.g. social workers, case managers), to develop and implement discharge support plans that address both clinical (e.g. medical home placements, prescription assistance) and non-clinical factors related to NMDOH uninsured and underinsured patients.
• Refers patients to appropriate internal and external resources, including medical homes, community-based organizations, and support programs, ensuring alignment with patient needs and eligibility.
• Documents all interactions, screenings, and referrals in Epic, ensuring accurate tracking of NMDOH indicators, navigation outcomes and follow-up needs.
• Identifies and tracks trends, common barriers and service gaps experienced by patients and escalates insights to program leadership to inform Community Health Network strategies and care design.
• Participates in community-based activitie