Job Description

Why Join Grace at Home?

Grace at Home is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to high-needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our patient’s race, culture, and environment is critical to delivering improved health outcomes. By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality—not a burden—every single day. Join us in creating a better way to care.

Position Overview:

The Community Care Navigator – Field (CCN - F) reports to the Non-Clinical Manager. They should embody Grace at Home’s core values, including, Trusted, Empathetic, Committed, Humble, Creative and Community-Minded. At Grace at Home, we don’t have family members or customers – we have Family Members .

The Community Care Navigator -Field (CCN- F) role has the responsibility of locating and engaging family members lost to care. This role is also responsible for connecting the member to a PCP and/or the Grace at Home Program, as well as completing SDOH assessments, basic health assessments, and making appropriate referrals for social, medical or behavioral needs.

Responsibilities

The Community Care Navigator – Field (CCN - F) will have the following responsibilities:

• Utilize Grace at Home resources and techniques for locating and engaging patients currently lost to care, including knocking on patients’ doors and visiting homeless shelters and community groups.
• Establish trusting relationships with community homeless shelters and community groups to help locate and engage patients.
• Establish trusting relationships with patients and their families while providing general support and encouragement.
• Work closely with medical and behavioral health providers to help ensure that patients are re-engaged with the appropriate health care providers.
• Work collaboratively with the Grace at Home clinical team to ensure patients receive timely care for acute issues.
• Act as a patient advocate and liaison between the patient/family and community service agencies.
• Record patient care information in the EMR and other software no later than 24 hours after patient contact.
• Be knowledgeable about community resources appropriate to the needs of patients/families. Provide referrals for services to community agencies as appropriate. Help patients connect with transportation and other resources and provide appointment reminders in special circumstances.
• Exhibit excellent working relations with coworkers, patients, visitors, and staff.
• Attend regular staff meetings, training, and other meetings, as requested.
• Always maintain HIPAA compliance.
• Perform other job-related duties as assigned.
• Leadership: The Community Care Navigator - Field (CCN - F) will lead in locating and engaging patients lost to care. This role will also lead in getting patients re-engaged with the health care system.

• Strategy: The Community Care Navigator - Field (CCN - F) accepts and readily adapts to changing priorities, new ideas, strategies, procedures, and methods.
• Collaboration: The Community Care Navigator - Field (CCN - F) will work closely with other members of the ICT to help address all Care at Home’s patients’ concerns in a timely and efficient manner.
• Knowledge: The Community Care Navigator - Field (CCN - F) will utilize all Care at Home resources, including data from the AI team, to locate and engage patients currently lost to care.
• Culture: The Community Care Navigator - Field (CCN - F) is accountable for creating a productive, collaborative, safe, and inclusive work environment for their team and as part of the larger Company. Represents Care at Home and its subcontractors by displaying a respectful and caring manner to our patients and their families.

Qualifications

The Community Care Navigator - Field (CCN - F) should have the following qualifications:

• Education: High school diploma is the minimum requirement; Associate’s Degree preferred. An understanding of community resources in the geographic areas the CCN is servicing.
• Experience: One year in a health services environment. Experience as a Community Health Worker or equivalent preferred. Proficiency in all Microsoft Office applications.
• Communication: Excellent verbal, written communication, and presentation skills; ability to clearly articulate information/education to the patients they are serving.
• Relationships: Ability to build a rapport with patients that allows the CCN to support and provide needed services to the patient/caregiver.
• Culture: Good judgment, impeccable ethics, and a strong team player; desire to succeed and grow in a fast-paced, demanding, and entrepreneurial Company.

Physical Demands

This role is a field role, requiring the Field CCN to be driving and walking most of the workday, and may include hills, and steps. The Field CCN may need to carry a backpack or bag (5-10 pounds). This is a year-round position, requiring the Field CCN to be outside in both winter and summer months. Manual dexterity is needed using a computer keyboard. While performing the duties of this position, the employee is regularly required to talk or listen. The employee needs to be able to see and frequently is required to use hands or fingers, handle, or feel objects. Must have a functional car and unrestricted driver’s license or be able to reach patients by public transportation.

Our Benefits

Financial Well-being

• Competitive Compensation: We offer competitive salaries to attract and retain the best talent.
• 401(k) with Employer Match: Plan for your future with our 401(k) plan and a generous 4% employer match.

Health and Wellness

• Comprehensive Medical Plan: We proudly offer a comprehensive medical option with an employer contribution.

• Dental & Vision Coverage: Maintain your oral and eye health with our employer-paid dental and vision plans via MetLife.
• Employer-Paid Insurance: Life, Short-Term Disability (STD), and Long-Term Disability (LTD) insurance are provided at no cost to you.
• Generous Paid Time Off: Enjoy ample time off for rest and rejuvenation with generous PTO, holidays, and wellness time.

Additional Perks

• Continuing Medical Education (CME) Allowance for Providers: Stay at the forefront of your field with our CME allowance.
• Commuter Benefits: Save on your commute with our commuter benefits program.
• Mileage Reimbursement: Get reimbursed for work-related travel expenses.

The working environment and physical requirements of the job include:

This position requires in-home, assisted living, and independent-living community based work. The job requires frequent travel for patient visits in all types of weather conditions. Work may be performed in settings with conditioned air, artificial light, and an open workspace.

In this position you will need an ability to travel frequently by car and/or public transportation, the ability to communicate with customers, vendors, management, and other co-workers in person and over devices, sometimes with people who are agitated. Regular use of the telephone and e-mail for communication is essential. Sitting or standing for extended periods is common. Must be able to receive ordinary information and to prepare or inspect documents. Lifting of up to 50 lbs. occasionally may be required. Good manual dexterity for the use of common office equipment such as computer terminals, calculator, copiers, and FAX machines. Good reasoning ability is important. Able to understand and utilize management reports, memos, and other documents to conduct business.

Job Tags

Similar Jobs