Community Resource Navigator

About the role

Become a part of our caring community. Are you passionate about helping people overcome barriers, access the care they need, and build healthier lives? As a Community Resource Navigator, you will be a trusted partner and advocate for members.

Responsibilities

• Conduct outreach to designated members through face-to-face visits, phone calls, and mail.
• Engage members who are difficult to reach or contact them in person when you are unable to contact them.
• Aid members in navigating health care and social service systems, including assisting with filling out applications, arranging transportation, scheduling appointments, and accompanying members.
• Coordinate access to basic needs such as food, housing, benefits, transportation, utilities, safety, and income supports.
• Communicate member needs related to prevention, wellness, medical care, behavioral health, care transitions, and Social Determinants of Health (SDoH) to the Interdisciplinary Care Team (ICT).
• Complete initial and periodic needs assessments, including barriers, basic needs, strengths, and SDoH.
• Help develop and implement member-centered care plans by helping members understand instructions and tailoring communication.
• Assess readiness to change and help members modify daily routines to support health goals.
• Provide informal counseling, motivational support, goal setting, and action planning.
• Support chronic disease management for members and their families.
• Identify and follow up on referrals to community-based resources.
• Develop partnerships with community organizations, including housing agencies/coalitions, shelters, food programs, and Aging and Disability Resource Centers.
• Document all member interactions, activities, and interventions in TruCare or designated systems.

Requirements

• 2+ years of experience with community resources, health agencies, or social services (e.g., Area Agency on Aging, DME providers, Meals on Wheels).
• 1 year of experience working with electronic documentation.
• Ability to travel up to 75%, within Southeastern/South Central Wisconsin.

Preferred Qualifications

• Community Health Worker training or certificate or willingness to complete within one (1) year.
• Bachelor's degree in social work or related field.
• Knowledge and ability to facilitate use of health care system (e.g. primary care and specialty linkages; appointment scheduling etc.).
• Experience with health education, promotion and wellness, chronic disease prevention and management and knowledge of health condition-specific treatment or management.
• Bilingual skills.

Additional Information

• Workstyle: Field Travel: Up to 75%.
• Workdays/Hours: 8:30-5pm (CST).
• Mileage reimbursement is provided for work-related travel.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
• Scheduled Weekly Hours: 40.