GENERAL SUMMARY:

Under the direction of the MSW, the Patient Navigator will work with participants and their families to assist with vital Social Determinants of Health issues including housing, food insecurity, benefits access and more. Incumbent will be proficient in providing traditional case management services in a professional and respectful manner with the goal of helping older adults live safely and comfortably in their homes and communities for as long as they can. The position entails extensive coordination, follow up and feedback to participants, IDT and community providers.

Essential Responsibilities:

• Attends IDT meetings; actively participates in team meetings by sharing pertinent information and providing follow up to assigned tasks. Supports the MSW team with the implementation of care plans to address older adult’s physical, social, emotional and environmental status needs by providing case management support. Consults with MSW appropriately.
• Knowledgeable regarding resources and services in the community that support participant wellness. Ability to research available community resources, services and programs.
• Refers participants and families to appropriate community services and acts as liaison and/or advocate with community organizations for participants (i.e. Housing Authorities, Department of Transitional Assistance, Social Security Administration etc.).
• Maintains professional, accurate and timely documentation in the participants’ medical records.
• Works collaboratively with fiscal /insurance department to maintain participant insurance benefits.
• Completes authorizations for home care and other approved services timely and accurately.
• Provides timely communication to appropriate staff regarding the following: (disenrollment, conversion to long term care, transfer of sites, participant and/or caregiver demographic changes).
• Reports allegations of abuse to appropriate state agency; provides support and resources to participant as he/she will accept; completes required documentation.
• Assists with referrals to skilled nursing facilities for short-term and/or long term admissions.
• Communicates with hospital case management; assists with discharge planning.
• Performs other duties as required.
• Frequent local travel to homes and community visiting.

Job Specification:

• Bachelor’s degree in Social Work, human service field or related field preferred or Associates Degree with significant relevant work experience preferred or equivalent years of related experience.
• Minimum of 1 year experience with older adults
• 1-2 years of case management experience preferred
• Current C. P. R. Certification or ability to become certified
• Ability to relate well to participants, to anticipate their needs and to encourage their independence
• Thorough knowledge of available community services.
• Ability to multi-task in a fast pace environment
• Excellent communication, organization and documentation skills
• Must have a valid driver’s license and reliable transportation
• COVID vaccinated preferred