SDOH Health Population Navigator - QIP - FULL-TIME DAYS (25449)

Job Duties

• Contacts patients post discharge per QIP-NJ contractual requirements.
• Communicates with patient Care Team members (physicians, behavioral health team and/or other health care providers) to provide patient with integrative care.
• Carries out tasks to execute the medical and support service plans including but not limited to guiding patients to appointments and accompanying them when necessary.
• Acts as the primary liaison with medical providers to ensure patient adherence to care.
• Tracks patient attendance for medical appointments, initiates outreach as well as adhering to missed appointment procedures.
• Captures treatment plan adherence.
• Captures deliverables per HORIZON ISC program.
• Maintains program database of community partners and referrals.
• Maintains documentation of all patient encounters and completes reporting requirements according to organizational and contractual requirements.
• Maintains strict confidentiality in accordance with state and agency policies.
• Attends and represents the organization at professional conferences, in-service training, and meetings at the request of or with the approval of supervisor.
• Flexibility with covering weekend/evening shifts.

Qualifications

• Experience working as a Community Health Worker, care coordinator, or patient navigator serving complex or vulnerable populations.
• Strong knowledge of SDOH, including housing instability, food insecurity, transportation barriers, benefits access, and other non-clinical drivers of health.
• Demonstrated experience with community-based referrals and resource navigation, including follow-up to ensure successful connections (closed-loop referrals).
• Familiarity with community-based organizations, county social services, and benefit systems.
• Strong communication, engagement, and documentation skills, particularly in interdisciplinary care settings.
• Experience working in healthcare, social services, or community-based settings, preferably within a safety-net or Medicaid-focused environment.

Benefits

• Comprehensive benefits package, including a competitive medical, dental, and vision plans.
• A generous time off policy that includes ample vacation days, personal time, sick leave and nine paid holidays.
• Commitment to the personal and professional growth of our employees, offering robust tuition reimbursement and continuing education programs.