Community Health Navigator - Alameda County, CA.

Position Summary: The Community Health Navigator (CHN) will play a critical role in supporting members as they transition from hospital to home and community-based care. The CHN will engage members and their families during inpatient stays and continue support after discharge through home and community visits. In collaboration with our internal RN clinical team, the CHN will assist with discharge planning, reinforce clinical guidance provided by the RN team, and help coordinate medication reconciliation. This role focuses on addressing both medical and social needs to reduce avoidable readmissions, increase care engagement, and improve overall health outcomes.

The CHN will serve as a trusted advocate for members, bridging gaps between the clinical team and the community, and ensuring members fully understand their discharge instructions and follow-up care. CHNs must also obtain consent from members before enrolling them into the program and providing ongoing services.

Reporting Structure:

• Reports directly to the Program Manager.
• Attends internal and external rounds calls to review member status, progress, and care coordination.

Key Responsibilities:

• Visit members during inpatient stays to establish rapport, assess needs, and support discharge planning.
• Conduct follow-up visits in members’ homes and community settings to reinforce discharge instructions, ensure follow-up appointments are scheduled and completed, and address barriers to care.
• Work closely with the internal RN clinical team to provide members with coordinated support, including clinical advice (from RN team) and help coordinate medication reconciliation.
• Identify and address social determinants of health, including housing, food insecurity, behavioral health needs, and transportation barriers.
• Provide coaching and health promotion to encourage self-management and adherence to care plans.
• Support members in navigating healthcare systems, scheduling appointments, and connecting with community resources.
• Document all encounters and activities in the designated system accurately and in a timely manner.
• Maintain a caseload of members, providing consistent outreach and follow-up.
• Demonstrate comfort working in hospital environments, members’ homes, and community settings.
• Track and report on member progress, escalating complex cases to the RN clinical team or program leadership as needed.
• Participate in interdisciplinary case conferences and team huddles to ensure coordinated care.
• Assist in quality improvement activities by identifying trends, barriers, and opportunities to improve program outcomes.

Transition of Care (TOC) Program Expectations:

• Obtain member consent before enrolling them into the TOC program and beginning outreach activities.
• Call the hospital to confirm whether members are still inpatient.
• If members are discharged (in the community), attempt a face-to-face visit at their home for post-discharge follow-up (PDFU).
• Call reminder and pending appointment spreadsheets regularly to support appointment completion.
• See members in the hospital every day. Some members require waiting for the census from Amerigroup; once received, CHNs will be informed of additional inpatients.
• See 8–10 members per day across hospital and community visits.
• Attempt outreach to TOC members on the caseload every week via phone call and face-to-face visit.
• Attempt outreach to Care Connect (CC and CC Plus) members two times per month via phone call and face-to-face.
• Order supplies for members as needed (e.g., blood pressure machines, glucometers, medical supplies).
• Enter notes daily in the designated system.
• Manage a caseload size ranging between 35–55 members, and assist with other programs as needed.

• High school diploma or equivalent required; associate or bachelor’s degree in a health-related field preferred.
•  Previous experience as a Community Health Worker, Medical Assistant, or similar role strongly preferred.
• Experience in hospital settings or care coordination programs a plus.
• Ability to collaborate effectively with the internal RN team to support discharge planning and care transitions.
• Comfortable working in hospital and community environments, including members’ homes.
• Physically able to walk within hospital units and conduct field/community visits regularly.
• Strong communication, motivational interviewing, and problem-solving skills.
• Bilingual skills a plus.
• Must have a valid driver’s license, reliable transportation, and proof of insurance.

Other Requirements:

• Ability to work independently with minimal supervision.
• Strong organizational and time-management skills.
• Commitment to improving health equity and supporting vulnerable populations.