Care Navigator, Primary Care

Overview

This position is primarily responsible for providing direct services to patients with complex care needs with the goal of increasing stabilization, safety, and well-being. Direct services include assessment, intervention, education, and linkage with needed internal and external resources and services.

Responsibilities

• Responsible for completing biannual reassessments with patients to include completion of a service plan in addition to seeing clients periodically to address their current needs and checking compliance to medical care and adherence HIV medications.
• The case manager is responsible for entering all patient data, and notes related to follow-up care and interventions, into the electronic medical record in a timely manner
• Assess patients for risk, protective factors, social issues and emotional well-being
• Assist patients in developing service plans addressing safety, stabilization, mental health and other social determinants of health
• Counsel with patients for stress reduction, stabilization, and crisis intervention
• Make frequent assessment to determine changes in the patient such as behavior or other circumstances affecting patient's well-being, and adjust service plan accordingly
• Assist patients with accessing both internal and external resources based on assessed need
• Prepare reports by collecting, analyzing, and summarizing treatment and results data
• Serve as a liaison between other organizations, service providers and Primary Care
• Make phone calls to remind patients and / or families of upcoming appointments.
• Accompany patients to their HIV primary care and supportive service appointments, as agreed upon by the patient such as appointments with internal and external providers in order to ensure appropriate accommodation for specific needs and other limitations.
• Provide assistance directly to and / or on behalf of the patient to facilitate access to services including primary medical care, social services, housing, entitlements and benefits. This may include assisting with any necessary paperwork, compiling eligibility documentation required by other service providers, and other tasks required to connect the patient to needed services.
• Conduct outreach for patient re-engagement when the patient misses an appointment
• Work with patient to develop self-care management goals
• Conduct one or more of the following planned activities in an effort to re-engage the patient if lost to care : phone call or text messages, email or letter follow-up.
• Attend required trainings, in-services, and webinars related to job function
• Perform other duties as required by supervisor.

Qualifications

Position Requirements :

Language Skills :

Skills :

Physical Demands :

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The salary range and / or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and can be modified in the future. When determining a team member's base salary and / or rate, several factors may be considered as applicable (e.g., site, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The statements herein are intended to describe the general nature and level of work being performed by employees and are not to be construed as an exhaustive list of responsibilities, duties, and skills required of personnel so classified. Furthermore, they do not establish a contract for employment and are subject to change at the discretion of One Brooklyn Health (OBH).

OBH is an equal opportunity employer, it is our policy to provide equal opportunity to all employees and applicants for employment without regard to race, color, religion, national origin, marital status, military status, age, gender, sexual orientation, disability or handicap or other characteristics protected by applicable federal, state, or local laws.