The bilingual care navigator works closely with the client to implement the goals identified during the intake, assessment, and reassessment process. As a direct patient care provider the care navigator gathers information to complete assessments and reassessments, participates in case conferences with other providers, conduct home visits, maintains contact with the patient’s extended family and informal support networks for coordination of care, accompany patients to/from medical appointments, assist patients to obtain entitlements and other services. In addition, s/he monitors patient progress in utilizing services, assists the care manager and other team members in implementing the individualized care plan.
Essential Job Functions
The following duties are mandatory requirements of the job:
¨ Gather information to complete assessments and reassessments.
¨ Conduct home visits and community follow-up to work in the community.
¨ Participate in case conferences with other providers.
¨ Attend supervisory meetings.
¨ Evaluate home environment through home visits.
¨ Maintain contact with the patient’s extended family and informal support networks.
¨ Escort patients to/from medical appointments.
¨ Monitor patient progress in utilizing services.
¨ Responsible for assisting the care manager and other Health Home team members in implementing the individualized care plan.
¨ Outreach via phone when patients have not kept important appointments.
¨ Outreach via phone to patients between visits (check on self-care, medication fills, treatment plan, schedules visits, tests/follow-up).
¨ Review patient’s historical or targeted clinical measurements (i.e. number of ER visits and inpatient psychiatric admissions).
¨ Monitor that the patient completes post-visit follow-up (fill prescriptions, make appointments).
¨ Prepare and follows-up on a list of patients who need preventive or metabolic screening, appointment reminders.
¨ Check that patients receive test results and tracks that patients follow up with medical directions.
¨ Electronically tracks all specialty medical, behavioral, and support service referrals made for patient, and ensures that the patient follows up and receives all of the care needed.
¨ Track that patients are seen within 24 hours of an inpatient psychiatric/medical stay.
¨ Identify the primary care physician or psychiatrist to provide ongoing care coordination as needed.
¨ Assist clients to obtain entitlements.
¨ Assists in crisis intervention.
The following duties are to be performed as assigned by the supervisor:
q Participate in CQI activities.
q Identify quality of care issues and refers to appropriate departments/services.
q Participate in conferences, workshops, and other professional development activities to remain professionally current in field.
q Participate in multidisciplinary task forces, committees and projects.
q Provides interpreter services as required.
q Participates in committees as directed.
q Attends staff trainings/meetings as scheduled by the supervisory team.
q Performs other related duties as required.
¨ Associate Degree in Social Service preferred or
¨ High School Diploma or equivalent plus + 1 year of relevant experience
Special skills and knowledge
¨ Computer skills.
¨ Knowledge of community resources and their financial requirements.
¨ Good oral and written communication skills.
¨ Good organizational skills.
¨ Good interpersonal skills.
¨ Good time management skills.
¨ Able to speak, read and writes English to the extent required by the position
¨ Bilingual Spanish required
Minimum Education Required