Community And Behavioral Navigator

Summary

Join CareBridge as a Community and Behavioral Navigator and become an integral part of our interdisciplinary team, providing telehealth services to managed Long Term Support Services (LTSS) patients. You will conduct holistic assessments, plan and coordinate care, and monitor patient progress. Collaboration with various healthcare providers and community resources is key to ensuring comprehensive care. This role involves facilitating interdisciplinary meetings, developing person-centered support plans, and delivering targeted interventions. You will also provide patient education, support compliance with medical appointments, and maintain detailed documentation. The position offers a remote work environment with potential for limited travel.

Requirements

• 3+ years’ experience of social service or community outreach experience
• Experience working with adult chronic disease patients and geriatric and IDD population
• Works and communicates well in a team environment
• Maintains a patient-centered focus
• Excellent communication skills
• Basic computer skills and understanding
• High School Diploma is required

Responsibilities

• Respond to referrals from the CareBridge team promptly, including participating in on-call rotation for emergencies
• Complete telephonic or telehealth psychosocial and economic or Social Determinants of Health (SDOH) assessment of patients
• Communicate effectively while performing telephonic interviewing and communication with external contacts
• Collaborate with Primary Care Physicians, Medical Specialists, Home Health, and other ancillary healthcare providers with the goal being to coordinate member care
• Anticipate members’ needs by continually assessing and monitoring the member’s progress toward goals, care plan status, and re-adjust goals when indicated
• Work with community outreach/member advocates to coordinate member care
• Collaborate with other CareBridge team members, health plan care coordinators, patients, and family to develop goals and interventions as appropriate
• Deliver targeted interventions for identified patients
• Facilitate Advance Care Planning discussions with patients and explanation of state-specific advance directive forms
• Provide patient education on disease state, available services, and resources
• Use motivational interviewing techniques to address patients' non-adherence and quality of life concerns
• Support compliance and assistance with maintaining medical appointments
• Maintain a working knowledge of available community resources available to assist members
• Coordinate services and referrals to assistance when needed
• Provides coaching around complex social situations and emotional distress
• Participate in interdisciplinary case conference discussions
• Document assessments and notes regarding care coordination in the CareBridge electronic medical record system
• Maintains excellent punctuality and attendance during work hours
• Perform other duties as assigned

Preferred Qualifications

• Bachelor’s degree in Social Work, Health Services, Behavioral Science, or related field
• Medicare and Medicaid experience preferred
• Bilingual English/Spanish language skills

Benefits

Remote work