Community Resource Navigator

Outer Cape Health Services; South Wellfleet (MA); On-site; USD 25,000 - 39,000; Full time

Job summary

Outer Cape Health Services Inc. is seeking a Community Resource Navigator to assess social determinants of health and connect residents to available resources.

You will collect data, document in Epic, and provide short-term care coordination under the Navigator Program Manager. You will build partnerships with human services, healthcare providers, and community organizations, maintain relationships, and help clients access wrap-around services while upholding confidentiality and working

Qualifications

• High school diploma or equivalent is required.
• Massachusetts driver’s license or ability to obtain one.
• Bachelor’s degree preferred.
• Experience with Epic or EMR systems desirable.
• Bi-lingual helpful.
• Experience in case management or navigation is preferred.

Responsibilities

• Conduct community-based assessments of social determinants of health.
• Assist clients with connection to available resources and supports.
• Collect required data and document in Epic or other EMR system.
• Provide short-term care coordination and individualized care planning.
• Coordinate referrals to behavioral health, substance use, and related services.
• Engage with partnering agencies to build durable relationships.
• Participate in CRN program meetings and committees as required.

Skills

Interpersonal skills

Communication skills

Organizational abilities

Computer skills

Bilingual (helpful)

Team collaboration

Education

High school diploma or equivalent

Bachelor’s degree preferred

Tools

Epic EMR

Outlook

Microsoft Office

OneDrive

Job description

Community Resource NavigatorOur Culture- Why work with us:Joining Outer Cape Health Services isn't just about taking on a new role; it's about embracing a mission that goes beyond the day-to-day. Here, you become part of a dedicated team committed to safeguarding and nurturing invaluable community health resources. Our ethos is built on creating a vibrant and inclusive workplace where every team member is valued and recognized for their unique contributions.Who We Are:Our mission is to provide a full range of primary health care and supportive social services that promote the health and well-being of all who live in or visit the ten outermost towns of Cape Cod.OCHS now cares for more than 20,000 patients annually, and no one is denied access to services due to an inability to pay. Founded in 1987 through the merger of Health Associates of Provincetown (established in 1972) and the AIM Medical Center in Wellfleet (established in 1966), Outer Cape Health has a long history of successful growth and expansion in pursuit of this mission. As a Patient-Centered Medical Home, OCHS holds itself to the highest standards. Ensuring patients have access to care when they need it and request it and validating that staff are working at the top of their licensures are the foundations of this model.Our Core Competencies:At Outer Cape Health Services, our core competencies are the foundation upon which our organization is built, guiding us in our mission to deliver exceptional health services to our communities. Our focus on fostering teamwork ensures that we operate as a cohesive unit, valuing each member's contribution and working synergistically towards common goals. Integrity and honesty stand at the heart of everything we do, creating a culture of trust and respect among our team and the communities we serve. Embracing technology, we continually seek innovative solutions to enhance our services and operations. Finally, being patient-centered, we prioritize the needs and well-being of those we serve, striving to exceed expectations and make a meaningful difference in their lives.A Day in the Life of this Role:Reporting to the Navigator Program Manager, the Community Resource Navigator will be responsible for conducting community-based assessments regarding social determinants of health and wellness needs, assisting community members with connection to available resources and supports, collection and documentation of required data, providing short term care coordination for individualized care planning.Summary of Duties:Identify at-risk individuals, contact them, explain program benefits/risks, enroll interested and eligible participants, collect required data, and deliver services.Regularly meet with representatives from across a broad spectrum of partnering community partnering agencies such as human services, health care providers, law enforcement, hospital emergency department, courts, emergency medical teams, social services, housing agencies etc. to forge and sustain durable relationships.Assist in coordinating the community’s human services and related resources on participant’s behalf.Establish contact, build and maintain effective relationships with identified clients.Assess each client’s history and needs using assigned screening/assessment tools.Stay connected with clients on a need- and resource-appropriate basis to ensure adherence to service plan.Track patient progress through contact and ongoing reassessment, collecting and inputting all required data into the required systems (e.g., Epic).In cooperation with client, OCHS clinicians, and community representatives, develop a treatment plan to engage clients with an appropriate range of service and treatment options.Facilitate clients’ navigation and utilization of wrap-around support and healthcare services.Facilitate and coordinate follow-up case conferences with referring agencies.Coordinate referrals to community substance abuse services, and mental health services as necessary.Collect and enter all Community Resource Navigator Program data to support assessments, tracking, patient registry, chart reviews, and patient satisfaction surveys.Actively participate in CRN program, behavioral health, departmental and general staff meetings and/or agency committees as required.As assigned, interact with referring resources such as Emergency Department inpatient behavioral health/substance use navigators from Cape Cod Hospital and other referring organizations in order to rapidly facilitate coordination and transition to OCHS programs such as OBAT, Healthy Connections or Care Coordination.Adhere to established case management standards of care.Adhere to OCHS policies and practices.Other duties and projects as assigned in order to meet the expectations of the position.Other related duties and projects as assignedCWhat we need from you:High school degree, or the equivalentValid Massachusetts driver’s license (or ability to obtainPreferred Qualifications, Education and ExperienceBachelors level educationExperience with Epic or other electronic medical records system desirable.Lived experience as a consumer of mental health or substance use services desirableExperience in engaging clients with mental health, substance use, trauma, and related social service challengesCase management, navigation, or community health worker experienceExcellent interpersonal skills, communication skills, organizational abilities, computer experience, and the ability to work within a collaborative team setting.Excellent written and verbal communication skills – bi-lingual helpfulWorking knowledge of and demonstrated computer skills, including EPIC, Outlook, Microsoft office, OneDrive etc.Excellent judgment and ability to solve problems in a timely manner.Ability to adhere to strict confidentiality standards.Demonstrated ability to work effectively both as a team member and independently.Demonstrated ability to work in a culturally diverse and inclusive environment