Patient Navigator

Why Work at AbsoluteCare?

At AbsoluteCare, we serve the most vulnerable individuals in America. These are our neighbors, people who are at higher risk for disease or who have multiple, complex, chronic illnesses. Often, they deal with an unequal healthcare system and wind up seeking basic care from emergency rooms. We take these patients out of those spaces and turn them into members: people who are entitled to some of the best, most focused care this country has to offer.

We call this “care beyond medicine.” We have turned the doctor’s office into a comprehensive care center. Here, we surround our members with a core care team of doctors, nurses, social workers, and medical assistants who have the time and skills to get to know our members’ needs. We make the most important services available to our members under one roof. This includes a pharmacy, X-rays, a blood lab, nutrition services, urgent care, and much more.

We don’t stop at our four walls. We engage members in the communities where we all live to find the people who need us most. Through these community care teams, we remove the barriers to healthcare that so many people face daily. And it works.

Our unique care is guided by our core values of accountability, caring, trust, and teamwork. We call it ACT2.

Job Summary

The role of Patient Navigator will support integrated syndemic (HIV, PrEP, HCV, drug user health), status neutral services within primary care at AbsoluteCare. The Patient will lead linkage, engagement, and retention services for individuals engaging with the continuum of syndemic services at AbsoluteCare Philadelphia at a local market level and coordinate activities between local efforts and shared services resources.

The Patient Navigator will be the in-market point of contact for all external partners to coordinate rapid, red-carpet linkage to care and treatment initiation services, including care and treatment initiation for individuals newly diagnosed or re-engaging with care, PrEP and PEP linkage, and other viral hepatitis and harm reduction services.

In addition to providing linkage to care services, the Patient Navigator will maintain a caseload of high-priority members for retention support across the Center’s syndemic services. In this role, the Patient Navigator will work collaboratively with PCP teams and members to address and resolve barriers to care.

This position will work in a fast-paced environment requiring exceptional organizational and interpersonal skills, this individual must non-judgmental and able to meet clients where they are at in the care process.

The work may involve travel to community-based organizations and clinics to assist in status-neutral linkage to care services at AbsoluteCare. The ideal candidate will be well versed in providing culturally competent and affirming care to individuals with diverse experiences through a harm reduction lens.

Duties and Responsibilities

70% Direct Member Support

• Provide in-person, virtual support and follow-up to members newly diagnosed with HIV and members re-engaging in HIV Care enrolling into AbsoluteCare’s medical services
• Provide advocacy, referral, and linkage services to address social determinants of health and other barriers to care (ex: intimate partner violence, housing insecurity, insurance)
• Support patients in navigating and accessing available Ryan White services as needed, and as appropriate
• Work with members to identify and address insurance related barriers to care, including accessing various coverage options for HIV treatment and PrEP, navigating LA-HAP (ADAP), Medicaid, and other patient access programs
• Coordinate educational workshops for members that promote and address self-advocacy, effective communication skills, and additional identified educational lessons as needed.
• Assist clients in navigating a complex medical system by building trust and a professional working relationship.
• Educate members on self-advocacy skills and empower them to communicate effectively with their healthcare team.
• Work in collaboration with the integrated pharmacy team and PCP team to support members who struggle with adherence and may need additional support to stay engaged in care
• Act as a liaison between social workers, clinic staff, and members as needed.
• Communicate any issues of concern (e.g., drug use, non-adherence) to the member care team.
• Check in regularly with members receiving syndemic services as appropriate
• Maintain client confidentiality.
• Document and provide pertinent information regarding services delivered in the EMR.
• Build rapport with community-based agencies to streamline referral processes for housing, domestic violence support, legal services, etc.
• Attend and participate in regularly scheduled staff meetings and conference calls.
• Work closely with other program navigators to plan and conduct navigation and outreach activities.

30% Program Coordination

• Work with Senior Manager of HIV/ ID and local market leadership to implement program in alignment with strategy
• Attend Population Health meetings as appropriate
• Coordinate designated member walk-in clinic sessions and other unanticipated walk-in members looking to engage in HIV testing, counseling, and linkage to care services, coordinate, and document follow-up plan for review at weekly Peer Navigator meeting.
• Represent AbsoluteCare with other local market leadership at community stakeholder meetings
• Work in collaboration with PCP teams and Shared Services in tracking and reporting KPIs across all syndemic services
• Work closely with the Senior Manager of HIV/ ID, local market leadership and PCPs to present local market data as needed in a digestible way
• Work closely with syndemic services team and champion staff to maintain and expand activities with community partners, including those listed as collaborating partners on key projects
• Work together with the Senior Manager of HIV/ ID to develop and maintain linkage to care protocols and procedures for local market, specifically adjusting for need and resources
• Electronic medical record report monitoring, work queues, and in-basket messaging for all PCPs (6 at present) related to non-clinical patient needs

Minimum Qualifications

• High School diploma or equivalent
• 5 years working in a related field with demonstrated knowledge of the HIV and/or harm reduction fields
• Experience with service provision, including insurance navigation, in Philadelphia and surrounding parishes
• Familiarity with HIV and HCV linkage to care and adherence best practices
• Basic understanding of Population Health approaches
• Ability to communicate and synthesize treatment information (i.e. care plans or disease state information) to patients in plain language
• Ability to represent AbsoluteCare in professional and community environments

Preferred Qualifications

• 7 years of experience working in HIV and harm reduction service provision in Philadelphia or surrounding EMA
• Knowledge and experience working within an electronic medical record, preferably ECW
• Bilingual – English/ Spanish

Working conditions

This job operates in the community and within a professional office environment. This role requires reliable transportation to commute back and forth between inpatient facilities and office; and routinely uses general office equipment.

Physical requirements

• Ability to communicate clearly and exchange accurate information constantly.
• Ability to remain stationary for long periods of time.
• Constantly operates computer, keyboard, copy and fax machine, phone, and other general office equipment.
• Job may be physically demanding at times.
• Repetitious Movements.

• Ability to occasionally move objects up to 20 lbs.

Direct reports

None