Community Health Patient Navigator (evenings)

About the role

The Patient Care Navigator provides in‑person support to patients in clinical settings such as emergency departments, inpatient units, or outpatient clinics. The role focuses on identifying and addressing non‑medical drivers of health (NMDOH), using advanced motivational interviewing to support behavior change, and helping patients transition to stable community care. By rounding, engaging patients with compassion, and collaborating with care‑coordination teams, the Navigator helps reduce avoidable emergency‑room utilization and preventable readmissions among vulnerable patients with chronic or ambulatory‑care‑sensitive conditions. Timely documentation in EPIC and identification of patterns or gaps are essential to broader system goals within the Community Health Network.

Responsibilities

• Conduct screenings to identify NMDOH and document patients’ risk levels for domains such as housing, food, and utilities within EPIC, determining eligibility for public assistance and community support programs.
• Use advanced motivational interviewing techniques to engage patients in behavior change, build trust, and explore readiness for action.
• Collaborate with care‑coordination teams (social workers, case managers, clinical staff) to develop and implement discharge support plans addressing both clinical and non‑clinical factors for uninsured and underinsured patients.
• Refer patients to appropriate internal and external resources, including medical homes, community‑based organizations, and support programs, ensuring alignment with patient needs and eligibility.
• Document all interactions, screenings, and referrals in EPIC, ensuring accurate tracking of NMDOH indicators, navigation outcomes, and follow‑up needs.
• Identify and track trends, common barriers, and service gaps experienced by patients; escalate insights to program leadership to inform Community Health Network strategies and care design.
• Participate in community‑based activities to identify new resources, maintain longstanding partnerships, and represent Memorial Hermann at special events supporting broader community health initiatives.
• Provide support at other locations within the Community Health Network (e.g., Community Resource Centers, Food as Health sites, CHW Hub) as needed to meet patient and program needs.
• Ensure safe care for patients, staff, and visitors; adhere to all Memorial Hermann policies, procedures, and standards, including budgetary specifications, time management, supply management, productivity, and quality of service.
• Promote professional growth by meeting mandatory/continuing education requirements, supporting department goals, and serving as preceptor, mentor, and resource to less experienced staff.
• Demonstrate commitment to caring for every community member by creating compassionate, personalized experiences and modeling Memorial Hermann’s service standards of safety, caring, personalization, and efficiency.
• Other duties as assigned.

Qualifications

• Education: High School diploma or GED required; Associate’s degree in a related field preferred.
• Licenses/Certifications (required): One of the following Texas Department of State Health Services (TDSHS) certifications:
  • Community Health Worker (CHW)
  • Community Health Worker – Instructor (CHW‑I)
  • Community Health Worker – Experience (CHW‑E)
  • Community Health Worker – Training (CHW‑T)
• Preferred certifications: Certified Patient Navigator (CPN) by the Patient‑Centered Education & Research Institute and Academy of Oncology Nurse & Patient Navigators (AONN+); Motivational Interviewing Certificate or training completion by TDSHS or Texas Health and Human Services (HHSC).
• Experience: Minimum three (3) years in healthcare or hospital settings, especially with underserved or high‑risk populations; experience providing in‑person bedside support to patients.
• Skills and knowledge:
  • Effective oral and written communication; ability to build trust and rapport across diverse populations.
  • Bilingual (Spanish) strongly preferred.
  • Proficiency with EPIC or other EHR systems; comfortable navigating digital documentation and referral systems.
  • Strong knowledge of NMDOH and community resources.
  • Excellent organizational and time‑management abilities; capable of managing multiple referrals and follow‑ups.
  • Collaborative teamwork while maintaining empathy, discretion, and professionalism.
  • Experience using Microsoft Office Suite (Word, Excel).