Lead Care Navigator

Fresno American Indian Health Project; Fresno (CA); On-site; USD 65,000 - 85,000; Full time

Job summary

Fresno American Indian Health Project is seeking a Lead Care Navigator to coordinate Native Wellness referrals and services. You will work with internal teams and external resources to develop care plans and address social, medical, and cultural needs.

The role involves triaging referrals, data tracking in NextGen, potential client transport, and collaboration across departments to ensure seamless service delivery.

Qualifications

• Bachelor’s degree from an accredited institution or equivalent preferred.
• Demonstrated experience of a minimum of 2 years in the provision of care coordination and/or case management services in a clinical or human service setting.
• Strong interest in providing culturally relevant services.
• Demonstrate ability to communicate effectively and professionally, both verbally and in writing.
• Demonstrate ability and willingness to work with culturally diverse populations, youth, and other community professionals.
• Knowledge of and/or sensitivity to the needs of the American Indian/ Alaska Native community.
• Valid California Driver’s license that is insurable on the company vehicle insurance policy.

Responsibilities

• Liaison integrated within all FAIHP departments to provide warm hand-off and/or linkage to resources and referrals.
• Responsible for coordinating the services and referrals for each client assigned.
• Administers brief client intakes to assess needs and make appropriate referrals.
• Establishes a course of action by exploring referral options with the client.
• Provides case management services to adults, youth, and families when needed.
• Establishes and maintains rapport with local resource agencies.
• May attend community partner meetings and client meetings (TDMs, CFTs, court hearings, etc.).
• Conducts community presentations and trainings as assigned.
• Attends community outreach events as assigned.
• Maintains appropriate documentation through the NextGen electronic health record system.
• Monitors referrals regularly and provides ongoing follow-up with clients and providers.
• Transports clients as needed for activities relating to the care coordination and treatment plan.
• Completes monthly and annual reporting for grants and FAIHP requirements.
• Provides feedback to care teams on care coordination issues.
• Assists with data collection efforts.
• Conducts data entry into electronic database that maintains client encounter information and referral information.
• Keeps Supervisor well-informed regarding activities, pending issues, and potential problems.
• Adheres to agency policies and procedures and advances the goals of FAIHP in a manner that embodies the agency’s philosophy.
• Maintains strict confidentiality of client and personnel information, adhering to HIPAA, professional codes of conduct, State of CA regulations, Privacy Act, and FAIHP policies and procedures.
• Ensures that referrals are tracked, completed, and closed to avoid gaps in care.
• Other duties as assigned or required to fulfill the purpose of the position.
• Will provide administrative support by performing a large variety of tasks to support the Director of Native Wellness.

Education

Bachelor’s degree or equivalent preferred

Job description

The Lead Care Navigator (LCN) is responsible for coordinating all Native Wellness referrals and services for clients, and collaborates with internal departments and external resources to develop care coordination and referral plans to address social, economic, academic, familial, cultural, medical, and other issues that impact the clients’ functioning and well-being. This position will serve on integrated care teams and provide triage for referrals received in the Native Wellness Department. May transport clients, and assists with a variety of client activities based on treatment and referral plan needs. The LCN is part of a multi-disciplinary team, and the majority of services are provided in the Native Wellness Department, but may be required to work interdepartmentally on referrals. The LCN will manage and track all referrals from beginning to end for the programs within the Native Wellness department. The Lead Care Navigator also monitors performance metrics, identifies opportunities for process improvement, and provides training and support to enhance team efficiency and effectiveness. May manage case load when needed in the department. The ideal candidate will have experience working with the Native American Community and/or other minority groups.

• Liaison integrated within all FAIHP departments to provide warm hand-off and/or linkage to resources and referrals
• Responsible for coordinating the services and referrals for each client assigned
• Administers brief client intakes to assess needs and make appropriate referrals
• Establishes a course of action by exploring referral options with the client
• Provides case management services to adults, youth, and families when needed
• Establishes and maintains rapport with local resource agencies
• May attend community partner meetings and client meetings (TDMs, CFTs, court hearings, etc.)
• Conducts community presentations and trainings as assigned
• Attends community outreach events as assigned
• Maintains appropriate documentation through the NextGen electronic health record system
• Monitors referrals regularly and provides ongoing follow-up with clients and providers
• Transports clients as needed for activities relating to the care coordination and treatment plan
• Completes monthly and annual reporting for grants and FAIHP requirements
• Provides feedback to care teams on care coordination issues
• Assists with data collection efforts
• Conducts data entry into electronic database that maintains client encounter information and referral information
• Keeps Supervisor well-informed regarding activities, pending issues, and potential problems
• Adheres to agency policies and procedures and advances the goals of FAIHP in a manner that embodies the agency’s philosophy
• Maintains strict confidentiality of client and personnel information, adhering to HIPAA, professional codes of conduct, State of CA regulations, Privacy Act, and FAIHP policies and procedures
• Ensures that referrals are tracked, completed, and closed to avoid gaps in care
• Other duties as assigned or required to fulfill the purpose of the position
• Will provide administrative support by performing a large variety of tasks to support the Director of Native Wellness
• Bachelor’s degree from an accredited institution or equivalent preferred.
• Demonstrated experience of a minimum of 2 years in the provision of care coordination and/or case management services in a clinical or human service setting.
• Strong interest in providing culturally relevant services
• Demonstrate ability to communicate effectively and professionally, both verbally and in writing
• Demonstrate ability and willingness to work with culturally diverse populations, youth, and other community professionals.
• Knowledge of and/or sensitivity to the needs of the American Indian/ Alaska Native community.
• Valid California Driver’s license that is insurable on the company vehicle insurance policy.

A clear background check, a drug screen, and a negative TB test are required for employment.

FAIHP offers a robust benefits package that includes: