ED Navigator - NSPG Care Management Program at North Shore Physicians Group(NSPG) in Peabody, Massachusetts

Job Description:

North Shore Medical Center is embarking on new innovative programming within the Emergency Department (ED) to improve coordination and continuity of care. The goal of the ED Navigator role is to connect patients who present in the ED with internal and external programs and services that will promote better health outcomes. The ED Navigator will engage specific cohorts of patients, create a trusting relationship, navigate patients to appropriate resources, and make follow-up phone calls. Specifically, the ED Navigator will connect patients to existing care management programs or primary care (establishing new primary care when needed), providing follow-up when appropriate. The ED Navigator will also identify patients, screen them for social determinants needs (e.g. food insecurity, violence/safety, transportation, housing, etc.), connect patients to appropriate programming and community partners, and work with a community health worker to provide outreach if necessary. The role will prioritize serving Medicaid patients.
Responsibilities

Connect with patients to complete an initial assessment, provide referral to internal and external services and programs with a focus on primary care and social determinants of health gaps, and develop a follow-up a plan as appropriate.
Manage follow-up with appropriate patients and provide continued connections to care systems and organizations, in a persistent manner for patients that are difficult to engage.
Collaborate with supervisor to optimize role both within the ED and in collaboration with other North Shore Health System clinics and with community programs, as appropriate.
Document each patient encounter using appropriate electronic tools. Track benchmarks of progress in care including short term goal completion.
Collaborate, advocate, and communicate with internal departmental resources and programs to link patients to appropriate services and ensure continuity of care.
Provide advocacy and support in accessing hospital and community-based programs.
Collaborate with care management team and/or community health worker to provide necessary outreach, if already enrolled, to ensure patient needs have been identified and addressed.
Provide culturally competent care to patients from multiple ethnic and cultural backgrounds utilizing interpreter services, when needed.
Coach and motivate patients, utilizing behavioral interviewing techniques, to identify and address barriers to accessing referred services.
Assess efficacy of systems in order to optimize and scale this role over time.

Experience

Required Minimum of 1 year experience working in a hospital, health center, or other health care setting
Preferred Experience working with surrounding community organizations
Experience working in a fast-paced ED or Urgent Care setting
Bilingual (preferably Spanish/English) and bicultural
EDUCATION
Required
BS/BA in Social Work/Public Health or related field

Partners HealthCare is an Equal Opportunity Employer & by embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law.