Elders Care & Service Navigator

Klamath Tribal Health; Klamath Falls, Northern (OR, KY); Hybrid; USD 42,000 - 58,000; Full time

Job summary

The Elders Care and Service Navigator at Klamath Tribal Health & Family Services serves as a central touchpoint helping Elders access and navigate health, wellness, and social services. The role emphasizes advocacy, culturally respectful guidance, and coordination across medical, behavioral health, and community programs.

Responsibilities include care navigation, resource connection, documentation in NextGen EHR, and building partnerships with tribal and community agencies to support

Qualifications

• Must have High School Diploma or Equivalent (submit copy).
• 3+ years of relevant work with Tribal communities, Elders, youth and families.
• Demonstrated knowledge of healthcare systems, social services, and aging programs.
• Working knowledge of Microsoft Office and Outlook Mailboxes.
• Ability to file and stay organized with electronic and hard copy documents.
• Valid Oregon Driver’s License with good driving record; insurable by program policy.
• Background/character investigation required per Tribal policy.
• Annual TB skin testing and adherence to immunization policy for healthcare workers.
• Must be a mandatory reporter per Tribal policy.

Responsibilities

• Care Navigation & Coordination: assist Elders in navigating healthcare, wellness, and social services within the organization and external agencies.
• Resource Connection: maintain knowledge of tribal, local, state, and federal resources and connect Elders to services such as transportation, housing, nutrition, Medicare/Medicaid.
• Advocacy & Support: advocate for Elders’ needs and address barriers to care including transportation and finances.
• Community Outreach & Relationship Building: develop partnerships with community agencies and participate in outreach events.
• Documentation & Data Tracking: record interactions and referrals in the EHR and support program evaluation.

Skills

Interpersonal skills

Communication

Confidentiality

Organizational skills

Multidisciplinary teamwork

Education

High School Diploma or Equivalent

Tools

Microsoft Office

NextGen EHR

Outlook

Job description

Description

Position Description

POSITION: Elders Care and Service Navigator

RESPONSIBLE TO: Elder Health & Wellness Program - Director

SALARY: Step 12-31: Full Benefits

CLASSIFICATION: Non-Management, Regular, Full-Time

LOCATION: Klamath Tribal Health & Family Services

3949 South 6th Street

Klamath Falls, Oregon

BACKGROUND: P.L. 101-630

Position Objectives

The Elders Care and Service Navigator plays a vital role in supporting the health, independence, and well‑being of Tribal Elders. This position serves as a central point of contact to help Elders access, understand, and navigate available services within Klamath Tribal Health and across community-based organizations.

The Navigator builds strong relationships with Elders, families, providers, and partner agencies to ensure coordinated, culturally appropriate, and patient-centered care. This role emphasizes advocacy, resource connection, and removing barriers to services.

Major Duties and Responsibilities

Care Navigation & Coordination

• Assist Elders in navigating healthcare, wellness, and social service systems within KTH and external agencies
• Coordinate services across departments including medical, behavioral health, patient registration, and case management
• Facilitate referrals and follow-up to ensure successful connection to services
• Support care planning in collaboration with providers and interdisciplinary teams

Resource Connection

• Maintain up-to-date knowledge of available Tribal, local, state, and federal resources
• Connect Elders to services such as transportation, housing support, nutrition programs, Medicare/Medicaid resources, and social supports
• Assist Elders with applications, enrollment, and understanding eligibility requirements

Advocacy & Support

• Advocate for Elders’ needs within healthcare and community systems
• Identify and address barriers to care including transportation, financial, or system navigation challenges
• Provide culturally respectful guidance that honors traditions, values, and preferences

Community Outreach & Relationship Building

• Build and maintain partnerships with community agencies, service providers, and Tribal programs
• Participate in outreach events, wellness fairs, and community engagement activities
• Serve as a liaison between Elders, families, and service providers

Documentation & Data Tracking

• Document all interactions, referrals, and services in the electronic health record system (e.g., NextGen)
• Track outcomes and service utilization to support program evaluation and improvement
• Maintain confidentiality in accordance with HIPAA and organizational policies

Like all employees of the Klamath Tribes, the incumbent will be called upon to accomplish other tasks that may not be directly related to this position, but are integral to the Klamath Tribes’ broader functions, including but not limited to, assisting during Tribal sponsored cultural, traditional, or community events that enable the successful operation of programs and practices of The Klamath Tribes as aligned with The Klamath Tribes’ Mission Statement. Some of these tasks may be scheduled outside of regular work hours, if necessary.

Knowledge, Skills, Abilities

Knowledge, ability and desire to learn the Olde Americans Act services, or Long-Term Supports

Ability to maintain strict confidentiality of medical records and adhere to the standards for health record-keeping, HIPAA and Privacy Act requirements.

Strong interpersonal and communication skills

Ability to build trust and rapport with Elders and families

Knowledge of culturally appropriate care practices

Strong organizational and problem-solving skills

Ability to work independently and as part of a multidisciplinary team

Proficiency with electronic health records and basic computer systems

Qualifications, Experience, Education

Minimum Qualifications: Failure to comply with minimum position requirements may result in termination of employment.

· REQUIRED to possess a High School Diploma or Equivalent. (Must submit copy of diploma or transcripts with application.)

· REQUIRED Three or more years of relevant work experience working with Tribal communities, Elders, youth and families

· REQUIRED Demonstrated knowledge of healthcare systems, social services, community resources, and programs related to elders, youth and families

· REQUIRED Working knowledge and experience with Microsoft Office programs and Outlook Mailboxes

· REQUIRED Knowledge, experience and the ability to file and stay organized with program materials, both electronic and hard copy documents

· REQUIRED to possess and maintain a valid Oregon Driver’s License, (out of state applicants must receive ODL within 90 days of hire), have good driving record and be insurable by the Klamath Tribal Health & Family Services’ vehicle insurance policy. (Must submit copy of driver license with application.)

· REQUIRED to submit to a background and character investigation, as per Tribal policy. Following hire must immediately report to Human Resource any citation, arrest, conviction for a misdemeanor or felony crime.

· REQUIRED to submit to annual TB skin testing and adhere to KTHFS staff immunization policy in accordance with the Centers for Disease Control immunization recommendations for healthcare workers.

· REQUIRED to accept the responsibility of a mandatory reporter in accordance with the Klamath Tribes Juvenile Ordinance Title 2, Chapter 15.64 and General Council Resolution #2005 003, all Tribal staff are considered mandatory reporters.

Preferred Qualifications

• Familiarity with Klamath Tribal Health systems and services
• Knowledge of the Older’s American Act, Elder Service programs, Area On Aging and programs supporting aging population
• Experience with care coordination or case management
• Knowledge of Medicare, Medicaid, and aging services systems

SUPERVISORY CONTROLS

Work is performed under the general direction of the Chief Executive Directpr and the Elder Health & Wellness Program - Director. This position requires sound judgment, strong organizational skills, time management experience, and the ability to work independently with minimum direct supervision. This position does not have supervisory duties and responsibilities.

Indian Preference

· Indian and Tribal Preference will apply, as per policy. (Must submit tribal documentation with application to qualify for Indian Preference).

ACKNOWLEDGEMENT

This position description is intended to provide an overview of the requirements of the position. It is not necessarily inclusive and the job may require other essential and/or non-essential functions, tasks, duties, or responsibilities not listed herein. Management reserves the sole right to add, modify, or exclude any essential or non-essential requirement at any time with or without notice. Nothing in this job description, or by the completion of any requirement of the job by the employee, is intended to create a contract of employment of any type.