SDOH Health Population Navigator - QIP - FULL-TIME DAYS (25454)

Bergen New Bridge Medical Center; Paramus (NJ); On-site; USD 47,000 - 60,000; Full time

Benefits offered by this job

Medical, dental, and vision plans

Generous time off policy

Tuition reimbursement

Continuing education programs

Job summary

Bergen New Bridge Medical Center in Paramus, NJ is seeking a SDOH Health Population Navigator to support patients with social determinants of health and care coordination. You will connect high-utilizers with community resources, document interactions, and collaborate with care teams to ensure follow-up.

The role requires strong communication, experience with social services, and the ability to work with diverse populations.

Qualifications

• Bachelor's degree in behavioral health required.
• Master's degree in behavioral health preferred.
• Experience with SDOH, referrals, and resource navigation.
• Experience coordinating for high-utilizers with complex needs.
• Spanish proficiency preferred.

Responsibilities

• Contacts patients post-discharge per program requirements.
• Coordinates with care team to provide integrative care.
• Guides patients to appointments and assists with transport when needed.
• Tracks attendance and initiates outreach for missed appointments.
• Maintains documentation and reporting per requirements.
• Maintains confidentiality and participates in trainings.

Skills

Community health worker

Care coordination

Patient navigation

Documentation

Interdisciplinary collaboration

Spanish (preferred)

Education

Bachelor's degree in behavioral health

Master's degree in behavioral health

Tools

EHR systems

Job description

Join Our Team at Bergen New Bridge Medical Center!**

We are dedicated to providing high-quality, compassionate care to our diverse community. As a leading healthcare provider, we offer a supportive and inclusive work environment. If you're passionate about making a difference and thrive in a collaborative setting, Bergen New Bridge Medical Center is looking for a The SDOH Health Population Navigator

Job Duties

• Contacts patients post discharge per QIP-NJ contractual requirements.
• Communicates with patient Care Team members (physicians, behavioral health team and/or other health care providers) to provide patient with integrative care.
• Carries out tasks to execute the medical and support service plans including but not limited to guiding patients to appointments and accompanying them when necessary.
• Acts as the primary liaison with medical providers to ensure patient adherence to care.
• Tracks patient attendance for medical appointments, initiates outreach as well as adhering to missed appointment procedures.
• Coordinates treatment plan adherence.
• Coordinates deliverables per HORIZON ISC program.
• Monitors internal data dashboard to coordinate patient care.
• Identifies community resources to address patients' social determinants of health.
• Provides referrals to community resources as needed and follow up to ensure referral completion.
• Maintains program database of community partners and referrals.
• Maintains documentation of all patient encounters and completes reporting requirements according to organizational and contractual requirements.
• Maintains strict confidentiality in accordance with state and agency policies.
• Attends and represents the organization at professional conferences, in-service training, and meetings at the request of or with the approval of supervisor.
• Flexibility with covering weekend/evening shifts.
• Performs other duties as assigned to support the overall objectives of the department and organization.

Core Competencies & Experience Needed

• Experience working as a Community Health Worker, care coordinator, or patient navigator serving complex or vulnerable populations
• Strong knowledge of SDOH, including housing instability, food insecurity, transportation barriers, benefits access, and other non-clinical drivers of health
• Demonstrated experience with community-based referrals and resource navigation, including follow-up to ensure successful connections (closed-loop referrals)
• Ability to work with high-utilizers and patients with complex medical, behavioral health, and social needs
• Familiarity with community-based organizations, county social services, and benefit systems
• Strong communication, engagement, and documentation skills, particularly in interdisciplinary care settings
• Experience working in healthcare, social services, or community-based settings, preferably within a safety-net or Medicaid-focused environment

Position Qualifications

• Excellent communication and interpersonal skills
• Experience working with behavioral health and/or substance use population.
• Experience working in a medical or social services environment preferred
• Strong attention to detail
• Proficient with computer databases
• Analytical problem-solving skills
• Ability to manage time, prioritize, and meet deadlinesAbility to work independently and as a team member
• Good attitude, professionalism, promote team attitude
• Proficiency in Spanish preferred

Education

• Bachelor's Degree in behavioral health field required
• Master's Degree in behavioral health field preferred

Salary Commensurate With Experience Within Posted Range

$47,000-$60,000/Year

We provide a comprehensive benefits package, including a competitive medical, dental, and vision plans. We prioritize work-life balance with a generous time off policy that includes ample vacation days, personal time, sick leave and nine paid holidays. Additionally, we are committed to the personal and professional growth of our employees, offering robust tuition reimbursement and continuing education programs to help support our employees ongoing development.

Please note that selection of the candidate for any position will depend on several factors, including the individual's educational background, skills, and professional experience