The Patient Navigator serves as a key member of the care team and assists patients in identifying and overcoming social, economic, and practical barriers that may affect their ability to access health care and achieve optimal health outcomes. The Patient Navigator screens patients for health-related social needs and connects patients with appropriate internal and community-based resources related to food, housing, transportation, utilities, safety, employment, childcare, and other social drivers of health (SDOH).

The Patient Navigator works collaboratively with patients, clinical teams, Financial Advocates, care management staff, behavioral health staff, and community partners to coordinate resources and promote successful connections to needed services. This position provides education, navigation, referrals, advocacy, and follow-up but does not provide clinical social work, psychotherapy, behavioral health diagnosis, or other services requiring professional licensure.

• Conduct standardized screenings to identify patients' health-related social needs and barriers to accessing health care.

• Review screening results with patients and identify needs requiring additional assistance, referral, or follow-up.

• Assess patient needs related to food insecurity, housing instability, transportation, utilities, employment, childcare, interpersonal safety, social support, and other social and economic barriers.

• Recognize when patient needs exceed the scope of the Patient Navigator role and appropriately escalate or refer the patient to clinical, behavioral health, care management, financial, or community resources.

• Support organizational efforts to improve completion and documentation of SDOH screenings.

• Assist patients in locating and accessing appropriate community resources and assistance programs.

• Provide information and referrals for food assistance, housing resources, transportation services, utility assistance, childcare, employment services, legal resources, and other community programs.

• Help patients understand eligibility requirements, application processes, and documentation requirements for community assistance programs.

• Assist patients with completing applications or connecting with organizations when appropriate.

• Make warm handoffs to internal and external resources whenever possible.

• Maintain current knowledge of available community resources throughout the organization's service area.

• Develop and maintain positive working relationships with community organizations, governmental agencies, nonprofit organizations, and other resource partners.

• Follow up with patients to determine whether they successfully connected with referred resources.

• Identify barriers that prevented successful connection and assist the patient with alternative resources when appropriate.

• Document referral status, outcomes, and follow-up activities in the electronic health record.

• Support closed-loop referral processes to ensure identified social needs are addressed whenever possible.

• Track unsuccessful referrals and resource gaps to help identify unmet needs within the communities served.

• Communicate significant barriers or unresolved needs to appropriate members of the patient's care team.

• Serve as a supportive resource for patients who experience barriers to accessing health care or community services.

• Help patients understand available resources and how to navigate complex health and community service systems.

• Promote patient self-sufficiency by providing education and tools that empower patients to independently access resources whenever possible.

• Advocate for patient needs while maintaining appropriate professional boundaries.

• Provide culturally responsive, respectful, and patient-centered assistance.

• Maintain patient dignity, privacy, confidentiality, and autonomy throughout the navigation process.

• Collaborate with medical, dental, behavioral health, pharmacy, care management, and other members of the interdisciplinary care team.

• Participate in patient care coordination activities, team huddles, case discussions, and other meetings as appropriate.

• Communicate identified social barriers that may interfere with treatment plans, medication access, appointment attendance, or other aspects of care.

• Coordinate with Financial Advocates when patients require assistance with insurance enrollment, financial assistance, billing, or the Sliding Fee Discount Program.

• Coordinate with clinical or behavioral health professionals when identified needs require assessment or intervention beyond the Patient Navigator's scope.

• Support organizational initiatives related to population health, care gap closure, patient access, health equity, and social drivers of health.

• Accurately and timely document patient interactions, screenings, identified needs, referrals, interventions, and follow-up activities in the electronic health record.

• Maintain appropriate documentation of community resource referrals and outcomes.

• Assist with tracking and reporting SDOH-related data and outcomes.

• Maintain confidentiality in accordance with HIPAA, organizational policies, and applicable state and federal requirements.

• Support accurate data collection for organizational, payer, quality improvement, grant, and regulatory reporting requirements.

• Participate in quality improvement activities related to social needs screening, referral completion, and patient outcomes.

• Maintain an up-to-date directory of community resources available to patients.

• Establish and maintain relationships with community agencies and service providers.

• Identify gaps in available community resources and communicate those needs to organizational leadership.

• Participate in community meetings, coalitions, or resource networks as assigned.

• Assist with developing partnerships that improve patients' access to needed services.

• Share information about new or changing community programs with appropriate staff.

• Demonstrate commitment to the organization's mission and the populations it serves.

• Provide services without discrimination and demonstrate sensitivity to cultural, socioeconomic, language, literacy, and other individual differences.

• Maintain professional boundaries and recognize the limitations of the Patient Navigator role.

• Complete required organizational training and maintain competency in assigned responsibilities.

• Participate in staff meetings, trainings, quality improvement activities, and organizational initiatives as assigned.

• Follow all organizational policies and procedures, including confidentiality, compliance, safety, and infection prevention requirements.

• Perform other duties as assigned that are consistent with the scope and purpose of the position.

• High school diploma or GED.

• Experience working with patients, customers, community organizations, human services, health care, social services, or a related field.

• Demonstrated ability to communicate effectively with individuals from diverse backgrounds.

• Ability to maintain confidentiality and handle sensitive information appropriately.

• Basic computer proficiency and ability to learn electronic health record and other organizational systems.

• Associate's or bachelor's degree in human services, public health, community health, health care, sociology, psychology, or a related field.

• Previous experience in a Federally Qualified Health Center, community health center, health care organization, nonprofit organization, or human services setting.

• Experience with social drivers of health screening and resource navigation.

• Experience working with Medicaid, Medicare, uninsured, underinsured, rural, or medically underserved populations.

• Familiarity with local and regional community resources.

• Bilingual skills based on the needs of the population served.

Professional social work licensure is not required for this position.

The successful Patient Navigator must demonstrate:

• Strong interpersonal and communication skills.

• Compassionate and nonjudgmental interaction with patients.

• Ability to establish trust and rapport with individuals experiencing challenging circumstances.

• Knowledge of or ability to learn community resources and public assistance programs.

• Strong organizational and follow-up skills.

• Ability to manage multiple patient needs and priorities simultaneously.

• Ability to work independently while functioning effectively as part of an interdisciplinary team.

• Problem-solving and resourcefulness when traditional resources are unavailable.

• Ability to maintain professional boundaries.

• Understanding of patient confidentiality and HIPAA requirements.

• Ability to document clearly, accurately, and objectively.

• Cultural humility and sensitivity to the needs of diverse populations.

• Ability to recognize situations requiring escalation to licensed clinical staff, leadership, or emergency services.

• Commitment to health equity and reducing barriers to health care.

The Patient Navigator is a non-licensed patient support position. The Patient Navigator does not independently provide services requiring professional clinical licensure, including psychotherapy, behavioral health diagnosis, clinical social work assessment, medical advice, or clinical treatment.

When a patient's needs require clinical assessment or intervention, the Patient Navigator will facilitate referral or escalation to the appropriate licensed health care professional.

Performance may be evaluated using measures including, but not limited to:

• Percentage of eligible patients completing SDOH screening.

• Number of patients with identified social needs receiving appropriate resource referrals.

• Percentage of referrals receiving documented follow-up.

• Successful connection or closed-loop referral rate.

• Timeliness and completeness of electronic health record documentation.

• Patient engagement with recommended resources.

• Identification and communication of community resource gaps.

• Collaboration with interdisciplinary care teams.

• Patient experience and satisfaction.

• Compliance with confidentiality, documentation, and organizational requirements.

• Work is primarily performed in a health care or office environment.

• Position may require interaction with patients experiencing financial hardship, housing instability, food insecurity, interpersonal safety concerns, or other challenging circumstances.

• May require occasional travel between organizational locations or to community organizations, meetings, or events.

• May require occasional participation in community outreach activities outside the primary clinic setting.

• Must be able to effectively communicate in person, electronically, and by telephone.

Reports To: Behavioral Health Director

Works Closely With: Medical, Dental, Behavioral Health, Care Management, Financial Advocates, Pharmacy, Front Desk, Community Engagement, and other members of the interdisciplinary care team.

The Patient Navigator helps ensure that social and economic barriers do not prevent patients from accessing health care or achieving their best possible health outcomes. Through screening, resource navigation, advocacy, coordination, and follow-up, the Patient Navigator connects patients with the resources they need while strengthening integration between health care and community services.