Community Health Worker (Navigator)

Why work with us?

We are a non-profit organization, passionate about providing the underserved population with medical and dental services across the greater Portland area, committed to making a difference daily.

• Competitive compensation and benefits package
• 20 days of PTO (based on full time employment)
• 9 paid holidays
• Health/dental/vision insurance
• Quarterly wellness reimbursements
• Generous 401k retirement plan with employer match
• Employer paid disability insurance
• EAP and life insurance
• NHC voted a Top Workplace in 2020, 2021, 2022, 2023, and 2024!

About the role

Community Health Navigators (CHN) are non-clinically licensed health care staff members who are frontline public health workers deployed in clinical and community care settings to improve the social health of Neighborhood Health Center (NHC) patients in the communities we serve.

Responsibilities

• Aid patients with social issues like houselessness, substance abuse, and mental health resources, and food insecurity resources, and assess need through social determinants of health (SDOH) screenings.
• Assist patients with organizing their medical care by making follow-up appointments, filling prescriptions, and connecting to specialty health as needed.
• Support patients through providing resources to connect to benefits and public assistance programs; examples are health insurance, food stamps, and other resources as needed.
• Initiate a follow-up call to patients who have been discharged from the emergency department or hospital following behavioral health crises within 24-48 hours post discharge. Assess and offer mental health resources, SDOH screening, care coordination, and scheduling with behavioral health and clinical pharmacy post hospital or ED visits.
• Build rapport with patients to engage them in their care plan, offering encouragement and guidance in addressing their behavioral health needs.
• Collaborate with the primary care team, Behavioral Health Consultants (BHCs), and external providers to ensure smooth transitions of care and continuity of services for patients' post-discharge.
• Connect patients to community resources that address social determinants of health (e.g., housing, food, transportation) that may impact their mental health or substance use recovery.
• Identify patients at risk for further crises and escalate cases to the care team or appropriate emergency services as needed.
• Maintain accurate records of patient interactions, interventions, and referrals in the electronic health record (EHR) system.
• Conduct regular follow-ups with patients to assess their progress, adherence to care plans, and any new or ongoing needs.
• Communicate all care and coordination activity, risks and care plans using standard documentation, information technology and care coordination tools in the electronic medical record.
• Be the system coordinator and point of contact for patients and families. May assume advocate role on the patient's behalf to ensure approval of the necessary services or accessibility of needed resources for the member in a timely fashion.
• Create collaborative relationships with staff across departments within Neighborhood Health Center, and externally, to promote collaboration and multi-system coordination.
• Increase access to health and health care services through innovative health models, virtual care strategies, and collaborative community partnerships.
• Apply motivational interviewing and patient centered approaches to address concerns around barriers to healthcare needs to improve the care experience and motivate patients to meet their health goals.
• Ability to work independently with accountability and exercise sound judgment, discretion, and professionalism at all times.
• Good organizational and time-management skills.

Qualifications

• Minimum two (2) years of experience in a community/clinic-facing role, addressing social determinants of health in a healthcare setting, navigation across health systems, and post hospital/emergency room visit outreach is required.
• High School Diploma or General Education Development (GED) is required.
• Completion of the approved state certified THW/CHW is required.
• Experience providing case management (or similar) services.
• Ability to work on multi-disciplinary teams.
• Experience working with ethnic, racial, economic, broad range of ages, and sexually diverse populations.
• Demonstrated computer proficiency using Microsoft Office (Word, Excel, Outlook) and working knowledge of the internet.
• Demonstrated excellent written and oral communication skills.
• Demonstrated ability to effectively collaborate with community stakeholders.
• Reliable transportation.
• Verbal and written fluency in English.