Community Health Navigator

The Community Health Navigator on the Community Partner team provides care coordination and connection to social services and community resources for people with medical and behavioral health needs. The Community Health Navigator is an active member of the Community Partner Care Team which also includes nurses, licensed behavioral health clinicians and a team administrator. The Community Health Navigator is supervised by the Care Team Leader and will learn about community resources, trauma/recovery skills, wellness coaching and how to conduct an assessment and develop a care plan. The Community Health Navigator must be willing to visit clients in their homes as well as work from our office.

The Community Health Navigator Will Also

• Outreach to and engage people referred to the Community Partner program.
• Coordinate the completion of the Comprehensive Assessment
• Conduct initial and ongoing risk assessment; design personal crisis management plans, relapse prevention and harm reduction strategies with members who have been identified as behaviorally complex in collaboration with team clinicians.
• Coordinate the development, implementation, and ongoing review of the care plan.
• Make referrals to any community or social services that align with the persons we are serving needs' and goals'.
• Collaborate and communicate with the client's other medical, behavioral health providers regarding changes in services, hospitalizations, and other care plan goals
• Obtain required Prior Authorization from Managed Care Plan for relevant/necessary services.
• Perform other related duties, as required
  
  

Summary

Responsibilities

The Community Health Worker (CHW) provides care coordination and care management for MassHealth Members with complex medical and behavioral health needs who are enrolled in an Accountable Care Organization (ACO) or Managed Care Organization (MCO) plan. The CHW collaborates with the Community Partner team and the clinical staff of each Enrollee’s ACO/MCO’s plan to minimize duplicative efforts, promote integrated care, ensure quality and continuity of care, and support the values of person-centered planning, Community First, and SAMHSA Recovery Principles. The CHW is at the helm of organizing and coordinating resources and services in response to the Enrollee’s healthcare needs across multiple settings, and inclusive of both LTSS and SDH needs. This role drives outreach and engagement, assessment and care planning, care transitions, health and wellness coaching, as well as community and social services connections in partnership with Enrollees and their care teams.

Job Duties And Responsibilities

The essential job duties/responsibilities of the position include but are not limited to the information listed below:

• Outreach to and engage Enrollees of an ACO plan as referred to CP Program.
• Coordinate the completion of the Comprehensive Assessment (CA).
• Conduct initial and ongoing risk assessment; design personal crisis management plans, relapse prevention and harm reduction strategies with members who have been identified as behaviorally complex in collaboration with team LPHAs.
• Coordinate the development, implementation, and ongoing review of the Person Centered Treatment Plan (PCTP) inclusive of any LTSS and / or SDH needs or goals of the Enrollee.
• Drive referrals regarding connections to any community or social services that align with the Enrollees needs and goals.
• Submit CA, PCTP, and all PCTP updates in accordance with the data sharing agreement CP and ACO/MCO Plan.
• Collaborate closely with PCP and other providers, including but not limited to community resources, to assure appropriate referrals based on level of care needed to optimize outcomes and minimize risk.
• Communicate and collaborate with ACO/MCO teams and serve as a team resource.
• Collaborate with ACO Plan, PCP, and other health care providers regarding changes in services, care transitions, and crisis intervention while focusing on continuity and quality of client care and potential efficiencies and cost-savings.
• Obtain required Prior Authorization from ACO/MCO Plan for relevant/necessary services.
• Manage all care transitions through collaboration with Enrollee, community provider staff, ICT, and hospital staff to ensure a safe discharge plan and a well-coordinated implementation of that plan.
• Ensure for medication review and reconciliation as triggered by a care transition or by a medication change through an outpatient medical or psychiatric visit.
• Perform other related duties, as required.
  
  

Knowledge And Skills

• Strong commitment to the right and ability of people served to live, work, have meaningful relationships, and receive the resources and supports needed in their community of choice
• Knowledge of person-centered, strengths-based, recovery-oriented values and principles and modalities
• Knowledge of clinical and psychiatric rehabilitation values, principles, and techniques
• Knowledge of health risks of prevalence with adults with SMI/SUD
• Knowledge of health promotion and clinical care coordination techniques
• Knowledge of motivational interviewing, stage of change, and harm reduction techniques
• Knowledge of trauma-informed and culturally responsive services
• Sensitivity to the cultural, religious, ethnic, disability, and gender issues
• Skills and competence to establish supportive trusting relationships with Enrollees
• Knowledge of human, legal, civil rights, community, and other resources
• Knowledge of empowerment and self-advocacy techniques
• Knowledge of available community health, mental health, and SUD services and resources
• Ability to triage/balance competing priorities
• Ability to make independent judgments and decisions
• Ability to work in a professional and confidential capacity
• Ability to work independently and as member of a multidisciplinary team
  
  

Typical Requirements

Minimum of 3 years care management experience preferred. Experience working with people living with SMI and/or SUD. Preference given to bi-lingual/bi-cultural applicants and those with lived experience of psychiatric conditions.

Preferred /Required Education

A high school diploma or equivalent is required; BA/BS in human-services related field preferred.

Driving Requirements

Driving is a requirement for this position using either a Vinfen van or personal vehicle. If using a personal vehicle, you must possess and maintain adequate insurance as well as maintain a safe driving record which is subject to annual checks. A valid driver's license must be presented at the time of employment. Incumbents must be at least 21 years of age, have maintained a valid US driver's license for at least one year, and must be able to pass a driver's screening background check.

Physical Effort

Ability to stand, walk, bend, kneel, stoop, crouch, crawl, climb as this is a very physically active position. Must be able to lift at least 25 pounds using proper lifting techniques or the use of a two-person lift. Ability to operate a computer and other office equipment such as a calculator, copier, and printer. Ability to sit, reach, climb stairs, and maneuver through narrow spaces or hallways. Ability to assist clients with tasks of daily living. Ability to remain in a stationary position 50% of the time as needed. Ability to bend, reach, file, sit, stand, and move around the facility. Ability to speak, hear, and communicate with clients, staff, and external representatives. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus. For positions in day programs or group residences, the ability to assist in routine living activities including cleaning, meal preparation, vacuuming, shoveling, and grocery shopping.

Required Certifications

CPR is required within two weeks of hire

First Aid is required within two weeks of hire

Required Credentials/Licenses

Certified Community Health Worker (CHW) preferred.

About Vinfen

Why Vinfen? We are committed to you! We offer great training, great benefits, career growth and job security!

Our Comprehensive And Generous Benefits Package Includes

• A fully funded, employer-sponsored retirement plan that requires no employee contribution as well as an employee-funded 403(b) plan
• First-rate Medical, Dental and Vision plans that are open all employees scheduled to work 30 hours per week or more. Plus, we offer a generous employer contribution toward the cost of medical insurance!
• Employer-paid Life, Accidental Death & Dismemberment and Long-Term Disability Insurance (no cost to you!)
• Employer-paid Short-Term Disability Insurance along with the option to purchase additional, voluntary, Short-Term disability insurance
• Flexible Spending Reimbursement Accounts (Health and Dependent care)
• Voluntary Term, Whole Life, Accident and Critical Care Insurance
• Generous paid time off (Employees scheduled to work 20 hours or more per week)
• Educational Assistance and Remission Programs
• $500 Employee Referral Bonus with no annual cap!
• Other generous benefits including discounted YMCA memberships, access to discounted movie tickets and more!
  
  

About Us

Established in 1977, Vinfen is a nonprofit, health and human services organization and a leading provider of community-based services to individuals with mental health conditions, intellectual and developmental disabilities, brain injuries, and behavioral health challenges. Our services and advocacy promote the recovery, resiliency, habilitation, and self-determination of the people we serve. Vinfen's 3,500 dedicated employees are experienced, highly-trained professionals who provide a full range of supportive living, health, educational, and clinical services in over 550 sites throughout Massachusetts and Connecticut. For more information about Vinfen, please visit www.vinfen.org/careers .

My Job. My Community. My Vinfen.

Vinfen is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, pregnancy, sexual orientation, gender identity, national origin, age, protected veteran status, or disability status.

Qualifications

• A High School Diploma or equivalent is required. Bachelor's degree in Human Services field strongly preferred
• A minimum of 1 year of case management experience; 2-3 years preferred. Experience working with people living Serious Mental Illness and/or Substance Abuse Disorder strongly preferred
• Strong organizational and collaboration skills
• Ability to prioritize work tasks and work both independently and as part of a multi-disciplinary team
• Ability to effectively represent the organization in a variety of circumstances and forum
• Driving is a requirement for this position. You must have access to a fully insured, licensed vehicle that you are willing to use in the course of your daily work.
• All candidates for this position must be a least 21 years of age and be able to pass a CORI, driving record, reference, multi-state background check
  
  

Pay Range

USD $50,000.00 - USD $50,000.00 /Yr.