Community and Behavioral Navigator

Community and Behavioral Navigator

Job Summary:

The CareBridge Community and Behavioral Navigator is an integral interdisciplinary team member that provides telehealth services to managed Long Term Support Services (LTSS) patients. Assists in the holistic assessment, planning, arranging, coordinating, monitoring, and evaluating outcomes and activities necessary to facilitate member access to healthcare services. Facilitates and participates in interdisciplinary meetings to facilitate coordination of services/resources for members. The CareBridge Community and Behavioral Navigator will work collaboratively with the Managed Care Organization's care management team to support the implementation of interventions according to the Person-Centered Support Plan (PCSP).

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.
• Potential for up to 20% travel as needed to meet patient needs.

Qualifications:

• 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

Preferred:

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

Those who thrive at CareBridge tend to possess these qualities:

• An entrepreneurial spirit. Must be a tenacious self-starter
• Flexible and adaptable to a constantly changing workload
• Must enjoy working in a fast-paced environment

• A sense of humor and a down-to-earth nature

Employment Type: Full-Time

Location: Remote