Community Outreach Navigator

MetroPlusHealth; New York (NY); On-site; USD 45,000 - 65,000; Full time

Job summary

MetroPlus is seeking a Community Outreach Navigator in New York, NY, to provide critical support and advocacy for individuals living with HIV. The role focuses on community engagement, conducting home visits, and collaborating with healthcare providers to improve patient care. Candidates should have an associate's degree or a high school diploma with relevant experience, along with strong interpersonal skills and cultural competency. Frequent travel and home visits are required, requiring comfort with NYC mass transit and potentially evening or weekend work.

Qualifications

• 3 years of professional experience in care coordination, health education, or case management.
• Experience working with vulnerable or marginalized populations, including knowledge of HIV.
• Field work experience preferred with comfort in conducting home visits.

Responsibilities

• Conduct independent home, hospital, or community visits to locate members at risk.
• Engage patients to assess barriers to care and support re-engagement.
• Collaborate with healthcare providers to coordinate member services.

Skills

Interpersonal skills

Problem-solving skills

Communication

Culturally competent engagement

Education

Associate’s degree in relevant field

High school diploma/GED

Tools

Microsoft Office

Electronic health record systems

Job description

Position Overview

The Community Outreach Navigator under the direction of the Community Outreach Supervisor plays a critical role in providing support, guidance, and advocacy to individuals living with HIV. This role is primarily responsible for community-based engagement through home visits, health facility outreach, and collaboration with healthcare providers and community partners to re-engage patients in care and improve health outcomes.

Scope of Role & Responsibilities

• Conduct independent, unaccompanied, home, hospital, or community field visits to locate members who are lost to care or at risk of disengaging from care, spending up to four to five days per week in the field.
• Engage patients in their homes, community locations, or healthcare facilities to assess barriers to care and support re-engagement with primary care services including accompaniment to medical or non-medical appointments.
• Provide health coaching and motivational support to empower members in staying connected to HIV primary care and treatment.
• Collaborate with healthcare providers, care managers, and community organizations to coordinate services that address member needs.
• Schedule medical appointments, arrange transportation, and facilitate medication access to remove barriers to care.
• Support HIV-positive Medicaid and HARP members to recertify their Medicaid, to engage in care with an HIV specialist provider, and to enroll into the HIV special needs plan through timely referrals.
• Track all medical, behavioral, and other referrals ensuring members attend appointments, through reminder calls and accompaniment when necessary.
• Monitor utilization including ER visits, hospitalization admission/discharge information, and behavioral health services to find opportunities for engagement with members.
• Document outreach efforts, patient interactions, and care coordination activities in the appropriate case management systems.
• Build trusting relationships with patients from diverse backgrounds using culturally sensitive and strengths-based approaches.
• Participate in case conferences, training sessions, and quality improvement initiatives.

Required Education, Training & Professional Experience

• Associate’s degree with 3 years of professional experience in care coordination, health education, or case management required; OR
• High school diploma/GED and 6 years’ experience in care coordination, health education, or case management required.
• Experience working with vulnerable or marginalized populations, including a strong knowledge of HIV.
• Field work experience is preferred.
• Frequent travel within the community is required.
• Must be comfortable conducting home visits and outreach in diverse settings by themselves.
• Must be able to navigate NYC by mass transit.
• Bilingual proficiency (English/Spanish or other languages) is highly desirable.
• Occasional evening or weekend work may be required.

Professional Competencies

• Strong interpersonal and communication skills to build rapport with patients and care teams.
• Ability to navigate community settings and conduct face‑to‑face outreach.
• Effective problem‑solving and organizational skills.
• Knowledge of community resources and healthcare systems.
• Proficiency with Microsoft Office and electronic health record systems.
• Culturally competent approach to patient engagement.