Job Description

POSITION SUMMARY: The Patient Navigator is a dedicated advocate and support professional who assists all patients in navigating the complexities of healthcare and social services. This role is designed to improve access to care, enhance patient understanding of health services, and ensure a seamless care experience through education, coordination, and connection to essential resources.

The Patient Navigator will conduct patient needs assessments, provide education on available services, assist with care coordination, and facilitate referrals to medical, behavioral health, dental, and community support programs. Working collaboratively with healthcare providers, pharmacies, insurance representatives, social service agencies, and community organizations, the Patient Navigator ensures that patients receive timely, appropriate, and comprehensive care. This role is essential in addressing barriers to healthcare, promoting health equity, and supporting patients in achieving their wellness goals.

KEY ACCOUNTABILITIES:

1. Works collaboratively with the Clinical Case Manager and Integrated Behavioral Health Consultant to bring support services to the client.

• Heath navigation and accompaniment services to medical requirements.
• Follow-up with patients regarding appointment reminders and counseling appointments.
• Assistance with transition of care for hospitalization and follow-up with PCP.
• Conducts weekly/regular calls to check-in, for encouragement, appointment reminders, and to reschedule missed appointments.
• Coordinates and assists with transportation.
• Works with the Integrated Behavioral Health Consultant to provide referrals and follow-up to Behavioral Health providers.
• 90% of patients referred to internal or external services are successfully connected within 14 days.
• Document navigation activities in the EHR for 100% of patient encounters within 72 hours of the initial encounter.
• Conduct over the phone outreach to schedule appointments for clinical measure gap closer.
• Monitor and follow up on patients who have been admitted to ER and released from inpatient care.
• Follow up with patients who conduct the after-hours provider coverage.

2. Conduct comprehensive patient needs assessments, including social determinants of health (SDOH), and connect patients to appropriate community resources.

• Conduct and document the PREPARE assessment to assess SDOH needs.
• Provide resources relating to the patient's needs.
• Achieve successful linkage to community resources (e.g., housing, food, transportation) for at least 80% of patients with identified needs within 30 days.
• Monitors patients for closure of needs.
• Maintains a resource guide for all PREPARE measures assessed.

3. Work collaboratively with healthcare providers, pharmacies, insurance representatives, and social service agencies to ensure coordinated care.

• Linkage services to onsite primary care, behavioral health, recovery programs, pharmacy services, and supportive housing services.
• Participate in 95% of scheduled care team meetings and provide updates on patient progress.
• Assist Medial Assistants with request for durable medical equipment (DME) and prior authorization requests.
• Achieve a patient satisfaction rate of at least 85% on navigation-related support (measured through patient survey.

4. Must support the organization in other duties as assigned.

KNOWLEDGE, SKILLS AND ABILITES:

1. Knowledge of the cultural and social characteristics of the Native American and ethnic minority populations in Maricopa County.

2. Maintain knowledge of community resources and programs along with eligibility criteria.

3. Knowledge of all Native Health Programs and services.

4. A willingness to go above and beyond to meet patient needs.

5. Knowledge of the economic and health constructs for Native Americans in Maricopa County.

6. Culturally responsive to all backgrounds.

7. Must possess excellent communication skills.

8. Bilingual Spanish speaker preferred.

9. Ability to manage multiple tasks and cases at one time.

10. Be detailed oriented professionally and be an effective leader who can work well with other health care personnel and interact in a culturally responsive way with patients and their families.

11. Knowledge of client confidentiality and client rights according to Health Insurance Portability and Accountability Act (HIPPA).

12. Ability to effectively function as a team member as part of Native Health.

13. Work collaboratively with healthcare providers, pharmacies, insurance representatives, and social service agencies to ensure coordinated care.

14. Must support the organization in other duties as assigned

Qualifications

QUALIFICATION/EXPERIENCE/REQUIREMENTS:

1. Must have a high school diploma or equivalent; an associate's degree, bachelor's degree or higher is preferable.
2. Preferred certified phlebotomist or willing to become certified.
3. Must have experience navigating and working in a clinical setting.
4. Must be familiar with working in a team environment.
5. Must be willing to work in community setting at outreach events.
6. Being bilingual is preferred but not required.
7. Flexible work hours may be required during evenings and weekends.
8. Must possess a valid and unrestricted Arizona driver’s license (within 30 days of hire if applicant is from out-of-state) with no DUI/DWI or reckless driving convictions in the last five years. No more than two at-fault accidents in the last three years. Must maintain a valid Arizona driver’s license during employment. Must be insurable under NATIVE HEALTH’s liability auto policy.
9. Must pass a criminal background check and obtain a Class I Fingerprint Clearance Card within the initial ninety (90) calendar days of employment and retain a valid card while employed with NATIVE HEALTH.
10. Must pass substance abuse testing upon employment and submit to random testing during employment.
11. Must provide an updated immunization (IZ) record at the time of employment.
12. Must have a current (within 12 months) Tuberculosis (TB) skin report upon employment and provide an annual update.
13. Must obtain Basic Life Support (BLS) certification within (90) calendar days of employment and maintain certification during employment.

Additional Information

Native Health complies with all state and federal requirements, including EEOC requirements.