Health Navigator (58981)

Summary of Position:

The Health Navigator is designed to work directly with and on behalf of indigent, unhoused, and uninsured patients who present frequently, and often for inappropriate healthcare needs, at local Emergency Departments with whom Circle the City has formal partnerships. The goal of the Health Navigator is to end the inappropriate overuse of emergency rooms and inpatient hospitalization by chronically unhoused individuals who are medically vulnerable and to assist them with their benefits, identification of a medical home at Circle the City and to work collaboratively with community partners for shelter, benefits, and housing assessment and placement. The Health Navigator is co-located within partner Emergency Departments and works with hospital clinical and social work staff to identify, screen, and refer these high-utilizing patients to more appropriate and less costly medical settings at CTC.

Essential Duties:

Duties include, but are not limited to:

• Outreach and Consumer Identification:

• Engage chronically unhoused/unsheltered, medically needy adults who are frequent users of hospital and emergency services annually.

• Assessment and Planning:

• Conduct patient screenings to evaluate social, mental health, and medical needs to create individualized action plans and move these patients from an emergency care model to a preventative primary care model.

• Direct Services and Coordination:

• Build rapport and trusting relationships with patients.

• Collaborate with healthcare providers, social workers, and case managers to connect patients to appropriate resource services in their area and serve as a patient advocate.

• Coordinate referrals and transition of care into Circle the City's Medical Respite Centers when appropriate.

• Work directly with shelter services, substance use treatment programs, mental health programs, and other community partners to secure placement and enhance coordinated discharges.

• Assist the patient to complete applications for appropriate programs and services that address needs including but not limited to housing instability, food insecurity, substance use, and transportation services.

• Assist patients to establish a primary care provider and schedule post discharge appointments to ensure any barriers to care are addressed prior to discharge.

• Maintain a working knowledge of economic, educational, and social problems of individuals facing homelessness and referral sources available preferred.

• Monitoring, evaluation and follow-up, advocacy and collaboration include

• Participate in multi-disciplinary team meetings as needed to coordinate patient services and review accomplishments.

• Document and track assessments and outcomes including encounters, contact attempts and action plans.

• Collect and report data to Circle the City leadership and hospital partners.

• All other duties as assigned.

• Possess and maintain a valid Arizona driver's license.