Care Navigator

The Care Navigator is a key role in the AC Care Alliance (ACCA). These individuals provide front-line support for members of the community with chronic, serious, or advanced illnesses and who may be at risk for avoidable ER visits or long-term care placement. The program is currently in six counties: Alameda, Contra Costa, Los Angeles, San Francisco, San Mateo, and Santa Clara. ACCA has two programs: the Advanced Illness Care Program and Enhanced Care Management. 

The ACCA Program is a community-based, person-centered, holistic care navigation intervention that focuses on three pillars of participant health, mental health, and social needs and encompasses ACCA’s original Five Cornerstones: spiritual, health (physical and emotional), social, advance care planning, and caregiving. It was founded in the African American faith community, it is free of charge and respects the needs and wishes of the participant, whatever their culture and faith. Care Navigators are trained members of the community who walk alongside participants, building trusting relationships, assisting the member in navigating health care and social service resource systems,  assessing and addressing social determinants of health (SDOH), developing  and implementing a participant-focused care plan, and providing specially-designed tools to empower them to achieve their identified goals. Services are delivered in-person and via phone for up to one-year. As ACCA continues to grow, it’s essential that team members stay agile and responsive to shifting responsibilities, new tasks, and refined processes. 

Because ACCA Care Navigators provide in-person services to members of the community who are both elderly and medically vulnerable, the individual hired for this position is required to be fully vaccinated for COVID-19, unless they are granted a reasonable accommodation under applicable law.   

This full-time position is currently hybrid, requiring regular in-person visits in participant homes and other appointments. The individual hired for this job must be able to work onsite as required. 

Full pay range for this position: $25.86 to $36.40 per hour. The starting wage is determined based on the candidate’s knowledge, skills, and experience, as well as budget availability. This job description is not intended to be all-inclusive or exact. Duties and responsibilities may be added, changed or removed, as needed, at any time, with or without notice. 

Essential Duties and Responsibilities

Program Outreach and Participant Eligibility 

• Provide information on the ACCA program and related training topics to individuals and organizations.  
• Develop and maintain relationships with referring health care providers, faith, and community organizations. 
• Identify individuals who may qualify for the ACCA program and determine eligibility. 
• Conduct outreach calls to pre-authorized individuals to schedule assessments. 

Delivering Program Intervention 

• Conduct thorough needs assessment 
• Review and obtain program consent and HIPAA authorization 
• Present assessment information succinctly at Case Conference and assist with the development of personalized goals and actions steps. 
• Utilize developed action steps to support participants to reach personalized program goals.  
• Conduct two (2) or more visits (at least one (1) face-to-face) per month per enrolled participant in their homes and community settings, accompanying members to medical or other program-related appointments when necessary. 
• Facilitate access to services, care coordination, and community resources, scheduling appointments and completing applications as necessary. 
• Motivate participants to be active in their health and overall wellbeing, taking care to empower individuals to participate in and lead activities upon program graduation. 
• Assist with problem-solving among individuals, family, and health care providers, reducing cultural and socio-economic barriers when possible. 
• Collaborate with ACCA team to ensure full section of services are implemented. 
• Comply with all ACCA HIPAA security policies and procedure and protocols regarding staff and participant safety 
• Maintain a full caseload based on assigned program and FTE. 
• Maintain professional presentation as relates to appearance and communication. 

Program Documentation 

• Utilize online case management system to accurately document client interactions and program activities within required timeframe. 
• Use Microsoft 365 to manage calendars, email, meetings, and to access program materials. 
• As directed, utilize approved secure methods for communicating with health systems, which may involve accessing medical records, verifying benefit eligibility, uploading care plans, member statuses, and releases of information. 

Training and Supervision 

• Attend ACCA team trainings virtually and in-person at ACCA locations. 
• Complete required Daily Action Plans and Reports for supervisor review. 
• Meet weekly with supervisor to review cases, update action steps, and prepare for complex visits. 
• Collaborate with Program Leadership and Quality Improvement team to improve personal performance and ACCA program process. 

Perform other duties as assigned. 

Minimum Qualifications

• Related work experience. 
• High School Diploma. Bachelor’s degree in public health or associated field preferred, but not required.  
• Live in county of assignment (or neighboring county and willing to travel). 
• Current driver’s license, reliable mode of transportation, and proof of insurance. 
• Must pass the background checks required for this job. 

Other Qualifications

• Experience and comfort working with the following populations is preferred:  

Persons with serious, chronic, and/or advanced health conditions 

Persons with behavioral and mental health conditions 

Persons with advanced social needs 

Seniors 

Diverse populations 

Faith communities 

• Experience and skills in the following areas is preferred:  

Health care and/or the desire to develop a health care career

Case Management/Navigation

Data entry and documentation

Finding resources and working with social services

Computer and tablet use, navigating electronic portals, Microsoft 365

Strong in-person, phone, and written communication; able to build relationships, manage difficult situations, and respond promptly to member needs

Bilingual (English/Spanish)

• Warm, compassionate, and empathetic attitude 
• Thrives in a fast-paced, complex, collaborative, and mobile work environment. 
• Ability to adapt to change and approach challenges with an innovative attitude. 
• Understand and appreciate the importance of spirituality, faith, and/or religion for a person’s holistic well-being. 
• CPR and first aid training preferred but not required.