Resource Navigator

The Resource Navigator is a trusted member of the team who supports clients within primary care to navigate health and social service systems to improve overall health and wellbeing. The Resource Navigator is an integral part of the primary care team. They provide responsive, trauma informed outreach, engagement, health education, care coordination, advocacy, and system navigation services primarily for individuals experiencing homelessness, poverty, behavioral health concerns, substance use, and other social determinants of health.

Essential Duties

• Conduct outreach to individuals in the clinic and community

• Build trusting, non-judgmental relationships with clients using a trauma informed approach

• Assist clients in accessing health care, behavioral health, housing, financial assistance, and community resources

• Advocate for client needs with service providers while supporting client autonomy

• Be an engaged team member of the Patient Centered Primary Care Medical Home care team

• Interviews clients/patients to obtain basic data, past medical history, etc.

• Implements individual and community assessment and treatment plans

• Deliver culturally relevant health education on topics such as preventative care, chronic disease management, sexual health, mental wellness, and substance use

• Support clients in understanding treatment plans, medication adherence, and self-management strategies

• Promote health literacy and help clients navigate insurance, benefits, and community systems

• Assist patients with paperwork and or referrals as needed

• Assist with MyChart navigation

• Assists in creating a positive and supportive work environment; enforces a safe workplace; establishes a culture of teamwork and communication; creates a workplace that promotes the organizational values and promotes an environment respectful of living and working in a multicultural society

• Foster and maintain up to date relationships with community partners, resources, organizations, and opportunities to remove barriers and ease access to services

• Follow up with patients who request resource assistance through the PRAPARE tool

• Meet with patients for warm hand-offs after primary care physician appointments to review and update care plan with Panel Care Coordinator and Integrated Behavioral Health Counselors 

• Participate in daily huddles, case consultations, interdisciplinary care planning and team meetings

• Communicate client updates, barriers, and successes to medical, behavioral health, and social service staff

• Provide peer level insight into community needs and support care team decisions

• Participate in process improvement projects pertaining to this role

• When necessary, accompany patients to appointments

• Maintain accurate, timely, and complete documentation of all patient encounters and complete reporting requirements according to organization standards 

• Track client contacts, referrals, outcomes, and care plans

• Follow HIPAA, 42 CFR Part 2, and organizational compliance requirements

• Follow up with patients when there are missed medical appointments and patient navigation sessions to initiate outreach and missed appointment procedures, as necessary. 

• Attend and represent the organization at in-service trainings, meetings, and professional conferences at the request of or with the approval of supervisor 

• Maintain strict confidentiality in accordance with agency policies

• Other duties as assigned

Knowledge and Skills

Knowledge

• Understanding of issues involved in mental health, substance use, sex work, houselessness, diabetes, and particularly all other whole person health issues related to primary care.  

• Knowledge of trauma informed care, harm reduction and comfortable around non-abstinence-based programs and environments 

• Experience and interest in working in an interdisciplinary team setting

Skills

• Proficient with Microsoft office Suite

• Ability to learn and document within organizational electronic health record system

• Ability to handle crises and multiple tasks in a setting with a high volume of patients.

• Excellent communication skills

• Flexible and adaptable in response to changing patient and health care providers’ needs

• Commitment to the mission of care coordination

• Passionate, trustworthy, and empathetic when working with patient

• Able to assist in warm hand-offs, sometimes in person, from agency to agency and/or assist with appointments such as with the DMV, Tri-Met, etc.

• Ability to work independently with timely follow through

• Ability to complete all required documentation and information input in a professional, thorough, and timely manner

• Ability to effectively navigate technologies used in this position including Epic OCHIN, MS Office Applications, and Windows Server

• Ability to travel to various sites, outreach, community, and networking events

• Ability to work with people from diverse backgrounds

• Ability to provide timely, effective, and efficient customer service to the community, clients, and other employees

• Ability to interact patiently with individuals making inquiries regarding various programs and services who may have little or no experience or knowledge of services provided

• Ability to communicate and express ideas effectively both orally and in writing with co-workers and community partners

• Time management skills, multitasking, and ability to work under pressure to meet deadlines

• Ability to learn and perform health screening tests that require simple math

• Ability to adhere to professional boundaries and ethics

• Must adhere to Federal and State OSHA guidelines, including timely completion of mandatory trainings

Education  Experience

• Two years of relevant experience and competency working with unhoused populations, people with behavioral health concerns, and/or people with chronic health conditions, required

• Credentialed as a Community Health Worker (CHW), required or within 6 weeks of hire

• Knowledge of various health issues, conditions, and cultural health practices of communities served

• Knowledge of healthy lifestyles and self-care strategies

• Knowledge of behavioral health challenges and their connection to physical health

• Knowledge of health behavior theories and basic public health principles

• Knowledge of the health and social service systems common in the United States as well as community health agencies

Working Conditions

This job includes working in a standard office environment, and may include a variety of community locations to support connection to resources. This means that the employee will meet with participants in community locations which may include the DMV, TriMet office, and other surrounding community settings.

Physical Requirements [adjust as needed]

This job requires operating phones, computers, and other office equipment. Communicating is required on a regular basis. Moving inside the building to other offices and program delivery spaces as well as moving to surrounding sites is expected. Sporadically moves boxes and/or items weighing up to 20 pounds. This position will require travel within the community with ability to drive being preferred.

Salary : $24 - $26