Community Health Navigator I

Works with an interdisciplinary team to support the complex medical and social needs of a multitude of patient populations under indirect supervision. Collaborates with the care team to seek standardization of processes across facilities and support multiple programs across the service area. Responsible for making connections to resources and other care managers and staff by sharing important community resources and practices with members and providers to ensure that the team meets patient care requirements. Coordinates alternative services for patients seeking non-clinical care and where other avenues of care are more appropriate to affect optimal patient outcomes, achieve continuity and quality of care and reduce cost (Triple Aim). Patient/family education on community resources and health services within KP will be a key component of success. This position will seek to improve patient/family engagement in management of health care needs through coaching, motivational interviewing and support in navigating KP and community resources which may include visiting patients in the home.

• Upholds Kaiser Permanentes Policies and Procedures, Principles of Responsibilities and applicable state, federal and local laws.
• Assist patients in problem solving potential issues related to health care delivery, financial or social barriers (e.g., request interpreters as appropriate, arrange transportation services or prescription assistance).
• Acts as the system navigator and point of contact for patients and families who suffer complex medical and social needs. May advocate on behalf of the patient or designee.
• Provides regular outreach to a panel of patients to identify social and medical risks upstream, and communicates these risks in the medical record, and coordinates care with the right team member or resource.
• Creates collaborative relationships with patients and clinical staff across a variety of areas within Kaiser and entities external to the organization to ensure patients receive quality healthcare services.
• Educates and advocates for the function in a variety of venues to increase awareness and understanding of the program and its contribution to the optimal patient outcomes, achieve continuity and quality of care and reduce cost.
• Works collaboratively with the complex care multidisciplinary team through active participation in routine meetings as necessary.
• Assists patients in connecting with community resources and health services within Kaiser Permanente as instructed by designated clinician on the team.
• Assists with non-clinical patient medical adherence and various forms of health coaching.
• Sees patients in a variety of settings including Medical Office Buildings, hospitals, homes, communities, etc.
• Travels to patients, including residences and community resources.
• Creates and maintains documents related to patient care.
• Provides regular outreach (which may include home visits) to patients to identify potential risks upstream, communicates these risks in the medical record, and coordinates care with the right team member or resource.
• Addresses patients chronic conditions and encourages care plan adherence.