Patient Navigator/Case Manager

Job Purpose

The Patient Navigator/Case Manager provides a unique role in patient care. This role focuses on addressing health disparities and improving health outcomes for individuals transitioning from the justice system.

The Navigator works directly with jail inmates, spending time within the jail facility to build relationships and provide case management services. The role also includes maintaining an external office space for follow-up care coordination and patient support. This dual presence ensures seamless care transitions, resource connection, and empowerment for patients as they reintegrate into the community.

By reducing barriers to care and fostering patient independence, the Navigator ensures that patients are connected to necessary resources, supported through transitions, and empowered to navigate healthcare systems successfully.

Essential Functions

• Assist patients transitioning from incarceration in accessing necessary services to establish a medical home and/or follow-up care.

• Provide case management and navigation services within the jail facility, working directly with inmates to identify health and social needs.

• Maintain an external office space to continue care coordination and support after patients are released from the justice system.

• Work with multi-disciplinary teams and external partners to identify patients who can benefit from intensive case management services.

• Provide tailored care coordination to address barriers and ensure timely treatment, focusing on populations targeted by the QTI-TJI grant.

• Build relationships with patients, healthcare providers, and community organizations to foster trust and collaboration.

• Assist patients in understanding and completing next steps in their treatment plans.

• Facilitate patient enrollment in programs such as the sliding fee scale (SFS) program or Prescription Assistance Programs.

• Support patients with dental referrals and follow-up processes as applicable.

• Collaborate with healthcare teams to ensure care plans address social determinants of health (SDoH) and patient-specific needs.

• Maintain comprehensive patient records, including profiles, referrals, appointments, and outcomes, in the electronic health records (EHR) system.

• Provide health education and coaching to empower patients to advocate for their own care and navigate systems independently.

• Serve as a reliable resource for patients by staying informed about program updates, community resources, and healthcare changes.

• Identify and address patient barriers creatively, seeking innovative solutions aligned with grant goals.

• Coordinate care transitions and communicate with patients and providers to reduce gaps in care.

• Promote patient health and comfort by addressing both physical and emotional needs.

• Collaborate with healthcare teams to identify opportunities to improve care processes and grant-funded program effectiveness.

• Empower patients through counseling connections and mental health resource referrals.

• Other tasks as needed to support the organization’s goals and grant requirements.

Qualifications

Education & Experience:

• Bachelor’s or Master’s degree in Social Work or Health and Human Services

• Previous experience providing outreach, referrals, and/or social services to diverse or high-risk populations

• Experience working in a Federally Qualified Health Center (FQHC)

• Comfortable and skilled with electronic medical records (EHR) systems

Skills & Competencies:

• Strong initiative and assertiveness in engaging with patients

• Proficient communication and customer service skills

• Proficiency with Microsoft Office Suite (Word, Excel, Outlook, PowerPoint)

• Knowledge of proper grammar, spelling, and rules of composition

• Ability to read, comprehend, and apply government statutes, policies, procedures, and guidelines

• Ability to research and utilize diverse information sources

• Detail-oriented and highly organized with the ability to prioritize

• Ability to work independently and collaboratively

• Strong problem-solving skills and customer/client focus

• Verbal and written proficiency in communication

• Proficient in multitasking and time management

Professional Attributes

• Results-oriented and transparent professional style

• Commitment to high-quality healthcare for underserved communities

• Flexible and adaptable with unquestioned integrity

• Strong planning, organizational, and change management skills

• Effective in a team environment

• Skilled in persuasive writing, active listening, and clear communication

• Deadline and detail-oriented with excellent analytical skills

• Capable of interpreting complex regulations and making sound decisions under pressure

• Ability to manage a diverse and demanding workload in a fast-paced environment

• Proven ability to manage highly confidential information

Work Environment & Physical Requirements

This position operates across professional office settings, the jail facility, and community spaces. It requires regular travel between locations and frequent interaction with diverse populations in varied environments.
While performing duties, the employee is regularly required to talk or hear, stand, walk, use hands to handle or feel, and reach with hands and arms.