Care Navigator
Position Title: Care Navigator (SF, Alameda, Contra Costa Counties)
Location: (Hybrid)
The AC Care Alliance (Care Alliance) established the Advanced Illness Care Program
(AICP) in 2014 to address health disparities and promote equity among individuals
with serious illnesses within the Black American and Latino/x communities. Currently
operating in six California counties, the program offers a holistic, culturally tailored
care navigation program to individuals with serious and chronic illness and their
caregivers. It focuses on the five most critical services that are least accessed by
people of color with serious or complex chronic illness: health navigation, social
support, spiritual and emotional support, caregiver support, and advance care
planning. With recent reforms to the Medicaid program in California, ACCA will deliver services and support of AICP through Enhanced Care Management (ECM) benefit. With ECM reimbursement, the Care Alliance can offer the tools and supports that
comprise the heart of the AICP intervention, plus additional services, including more
intensive care coordination offered over a longer period.
Position Summary
The Care Navigator is a key role in the AC Care Alliance (ACCA). These individuals provide front-line support for members of the community, referrals from health care systems, and ACCA congregations who are caregivers and individuals with advanced illness. The program is currently in several counties in the San Francisco Bay Area and in Los Angeles County.
The ACCA ECM-AICP program is a community-based, person-centered, care navigation intervention serving individuals with advanced illness and their caregivers in partnership with health, faith, and community organizations. Founded in the African American faith community, it is free of charge and respects the needs and wishes of the participant, whatever their culture and faith. Care Navigators are trained members of the community who walk alongside participants providing trusted referrals, resources, and specially designed tools to empower them to achieve their identified goals. The intervention is holistic in its approach by focusing on participant needs within our Five Cornerstones: spiritual, health (physical and emotional), social, advance care planning, and caregiving.
Care Navigators are trusted, well-respected individuals from the community and/or ACCA churches. While they are not medical professionals, Care Navigators are well trained in the execution of the ACCA program, providing a person-centered, holistic approach to relationship building, service delivery, and case management. This incorporates foundational skills in motivational interviewing, storytelling, and story-listening to better understand the multiple needs of each participant. Navigators are also trained to use tools developed for the program as well as the case management technology solution to document their work. Care Navigators personalize the program to meet individual participants’ needs. All 5 cornerstones and a subset of resources and tools can be utilized, depending on the needs of the participant.
This position will work with patients referred through community organizations, churches, and by health system partners. ACCA’s model is to provide some participant visits in-person and others by phone, however the program has resumed in-person visits and follows appropriate COVID precautions.
This full-time hybrid position requires regular in-person visits in participant’s homes and occasional in-person meetings for up to 70% of the regular schedule.
The individual hired for this job must be able to work onsite as required.
Bilingual in English and Spanish is preferred.
Full pay range for this position: $25.86 to $36.40 per hour. The typical hiring range for this position is from $25.86 (minimum) to $31.13 (midpoint) per hour. The starting wage is determined based on the candidate’s knowledge, skills, and experience, as well as budget availability.
Essential Duties & Responsibilities
Program Outreach and Participant Eligibility
- Conduct outreach activities to provide information on the ACCA program to referred patients and community organizations.
- Build and manage both new and current relationships with referring health care providers and organizations.
- Through referral and/or outreach, identify individuals who can benefit from and may qualify for the ACCA program.
- Assist other team members with facilitating training on program related topics.
- Determine program eligibility for identified individuals from the health systems, community, or ACCA congregations.
Delivering Program Intervention
- Review consent forms and provide program overview for individuals.
- Obtain consent from individuals to enter a working relationship.
- Conduct assessment of 5 cornerstone needs and gather intake information.
- Clarify areas of need, available resources, and sources of support and develop a plan in collaboration with individuals.
- Facilitate access to services, taking care to empower individuals to take active steps to access resources.
- Provide visits per assigned program member, via phone and in-person.
- Assist with problem-solving among individuals, family, and health care providers.
- Work closely with ACCA and health system pilot team to ensure proper report-back procedures are followed.
- Partner closely with faith & health ministry leaders of assigned churches, for church-specific referrals.
- Comply with all HIPAA confidentiality requirements.
Program Documentation
- Utilizing online case management system, track and document required program activities during each visit within 48 hours of occurrence.
- Use Microsoft 365 to manage calendars, email, virtual meetings, and secure documentation and accessing program materials.
Health System Pilot Work
- As directed, utilize approved secure methods for communicating with health system patient’s primary care physician, which may involve accessing health system’s electronic medical records system.
- Adhere to all applicable health system compliance requirements including annual trainings, current immunizations, background check, drug testing, and annual flu vaccine and TB testing.
Trainings and Supervision
- Attend bi-monthly ACCA team meetings virtually and in-person at ACCA locations.
- Supervise volunteers, as applicable.
- Assist with training for new Care Navigators and Care Team members, as requested.
- Collaborate w/ Program Leadership Team and health system partnership team to improve personal performance and pilot program process.
*Perform other duties as assigned.
Work Environment and Job Requirements
- Ability to lift and carry up to 25 pounds regularly and up to 50 pounds occasionally.
- Ability to assist clients with mobility, including entering and exiting vehicles and use of mobility aids (e.g. wheelchairs, walkers).
- Ability to stand, walk, bend, and reach as part of normal duties.
- Ability to travel within the service area and work in client homes and community settings
- Must have reliable transportation to travel between client sites and community locations, including a valid driver’s license and proof of insurance if driving a personal vehicle. *Perform other duties as assigned.
Minimum Qualifications
- 3 years of related experience.
- 1 year of Case Management or Care Navigation experience or 2 years of experience working in the health care field and/or working with individuals with advanced stage illness.
- High School Diploma.
Other Qualifications
- Some experience and comfort working with the faith community.
- Experience working with seniors and/or persons with chronic and serious health conditions is highly preferred.
- Some work experience in the health care field and/or the desire to develop a career in health care is preferred.
- Experience in community outreach, working with social service agency, advocacy with behavioral and mental health is a plus.
- Demonstrated relationship building experience is highly preferred.
- Strong verbal and written communication skills.
- Computer proficiency and comfort with technology.
- Understanding of and ability to comply with all HIPAA and confidentiality requirements.
- Interest in working with diverse communities with advanced illnesses.
- Thrives in a fast-paced, complex, and mobile work environment.
- Compassionate and empathetic attitude towards clients, patients, and customers.
- Understand and appreciate the importance of spirituality, faith, and/or religion for a person’s holistic well-being.
- Must have access to available and reliable transportation and have the ability to travel locally for in-person meetings, home visits, and church visits in the county assigned.
- Bachelor’s degree or equivalent education is preferred.
- Must be able to pass the background checks required for this job.
Pay: $25.86 - $36.40 per hour
Expected hours: 40.0 per week
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Disability insurance
- Flexible spending account
- Health insurance
- Health savings account
- Life insurance
- Paid sick time
- Paid time off
- Vision insurance
Work Location: On the road
