POSITION SUMMARY: The Diabetes Care Navigator assists patients of Esperanza Health Center (EHC) with diabetes with completing the recommended care to manage their diabetes and prevent future complications. This includes but is not limited to: performing outreach to patients overdue for laboratory testing and retinopathy screenings; assisting with referrals for identified barriers related to social drivers of health (SDOH); and connecting patients with other EHC and community resources. This team member also assists with performing outreach and providing referrals for patients with prediabetes for any community Diabetes Prevention Programs, as needed. 

The Diabetes Care Navigator works closely with the Diabetes Care Coordinator to care for this population of patients. This is a part time position: 25 hours per week.

ESSENTIAL FUNCTIONS

• Collaborate with the Associate Medical Director for Community Health and Wellness, Population Health, and Clinical Quality Assurance and Diabetes Care Coordinator to perform outreach to patients identified as high risk.  

• Perform outreach for patients overdue for diabetes labs and/or appointment with the primary care provider to ensure adequate follow up is achieved.

• Perform outreach for patients overdue for retinopathy screening; liaises with ophthalmology and optometry offices to ensure that records are received for referral loop closure.

• Support Diabetes Care Coordinator with events on site at EHC scheduled with outside partners to facilitate the completion of recommended health screenings for patients with diabetes (including but not limited to retinal screening clinics). 

• Connect patients to resources to assist them in controlling their diabetes, including but not limited to:

  • Nutrition classes or visits

  • EHC Lifestyle Medicine classes

• Identify barriers related to diabetes control including Social Drivers of Health (SDOH) and connect patients with necessary resources.

• Collaborate with Esperanza health care team members (e.g. behavioral health, care management, social services) and outside agencies (e.g. The Simple Way, Manna, etc) as needed to address barriers to controlling diabetes.

• Collaborate with outside organizations to refer patients to and support the Diabetes Prevention Program on site, or at location of program, as needed. 

• Position requires 15-25 hours per week.  The position requires at least 8 hours of work on site per week Monday through Friday.

• May work up to 4 hours one Saturday per month with supervisor approval. 

COMPETENCIES

• Self-directed and motivated.

• Ability to effectively provide clinical care to socially and medically complex patients in a variety of non-traditional settings

• Exceptional organizational and interpersonal skills, with attention to detail required.

• Strong written oral/written communication is required.

• Competency in Google Suite, knowledge of database and data analysis preferred.

• Ability to work collaboratively in a team and manage multiple priorities, utilize effective time management skills, and exercise sound administrative and clinical judgment.

• Ability to analyze systems and to develop creative solutions to problems.

• Demonstrated cultural humility, strong cross-cultural sensitivity and experiences, required.

• Requires the ability to travel to multiple office locations.

• Provides effective spiritual intervention with patients, sharing hope and salvation through Jesus Christ, sharing helpful Biblical instruction and scriptures, praying for patients, and connecting/referring to Christian churches as appropriate and according to the leading of the Holy Spirit. Does not force spiritual intervention, but gives spiritually uninterested patients respect and space, continuing to provide exemplary care in all other dimensions.

• Serves all patients in a Christ-like manner, with respect, humility, love, and self- control.

KNOWLEDGE, SKILLS, AND QUALIFICATIONS

• High school diploma or equivalent.

• Spanish language proficiency preferred

• Demonstrable maturity and professionalism in the workplace.

• Knowledge of North Philadelphia communities, an understanding of the barriers to health and experience supporting individuals with behavior change preferred.