Community Health Navigator

CHI Health St. Mary’s has served Nebraska City and the surrounding areas since 1927. In the fall of 2014 St. Mary’s opened the doors of a brand-new fully modernized facility. The new 110000-square-foot campus is better equipped to meet the changing needs of our community with among other benefits an increased capacity for specialty clinics and an integrated primary care clinic. St. Mary’s encourages collaboration and care coordination among primary care physicians and medical specialists. This contributes to the high quality of care our patients have come to expect.

JOB SUMMARY / PURPOSE
Community Health Workers (CHW) provide non-clinical interventions to engage patients in their care and connect them to community support. This person plays a crucial role in helping patients and their support networks navigate
healthcare systems and access community resources. The CHW will assist in care management through outreach, social support, and informal counseling, fostering positive relationships with patients while advocating for their health needs.

The CHW will provide support to participants by providing referrals to community based organizations for identified needs (e.g., transportation, food, and housing) that directly impact the participant’s short- and long-term health. The
CHA will be an integrated part of CHI Health and will work directly with participants, as well as build and maintain relationships with community resource partners.  The CHW may work in the clinic, Emergency Department, other
hospital settings, in the community and in the patient’s home depending on program needs.

ESSENTIAL KEY JOB RESPONSIBILITIES
1. Working with clinicians, nursing staff, and other care team members to identify patients with Substance Use Disorder (SUD).
2. Conduct initial assessments, obtain patient histories, and provide brief interventions that introduce options for SUD services, including Medication for Addiction Treatment (MAT).
3. Facilitate MAT initiation with on-site clinicians, coordinating with outpatient providers, and ensuring seamless access to pharmacy services.
4. Collect and maintain health-related social needs screening data and documenting patient interactions in the electronic medical record (EMR), and other program documentation in a timely manner.
5. Establish trusting relationships with patients and their support teams, providing guidance, encouragement, and ongoing follow-up. Assist patients with completing necessary applications and registration forms. Act as a peer support and advocate for participants as they navigate the medical and social service system.
6. Coordinate with healthcare providers, services, and community agencies to ensure patients receive appropriate support.
7. Provide referrals for community services, including transportation resources, financial counseling, primary care, mental health services, and residential treatment facilities. Identify and link participants and families to community resources and services, assisting with coordination as necessary.

8. Offer continuous follow-up via phone or in-person visits to track patient progress, encourage appointment attendance, and remind patients of upcoming commitments.
9. Support the hospital Narcan Naloxone Distribution Program.
10. Verify eligibility, complete consent form, and all documentation (Release of Information, Demographic Form, Visit Form, Progress Form and Standard Pathways) and tools as needed for enrolling the population being served;
11. Work with enrolled participants and families on needs that could affect the participant’s health, and connect them to community-based resources and services to remove barriers to care, including transportation issues, housing, financial concerns, etc. 
12. Build and maintain relationships with local networks of resource providers including: attending local coalition and partner meetings as needed; identify gaps in community resources based on participant needs.
13. Play a consistent and active role in identifying project inefficiencies and collaborative solutions.
14. Collecting and compiling data for monthly or quarterly counts of targeted metrics, such as number of patients served, buprenorphine administrations, prescriptions, referrals to care, etc. for program reporting. Attend team meetings and care conferences as appropriate as well as grant required training and meetings.

The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned.

Required Education and Experience 

• Associate Degree

Required Licensure and Certifications  

• Within 18 months of hire, must obtain certification through Nebraska Department of Health & Human Services (DHHS) to become a certified Community Health Worker (CHW) in Nebraska.

Required Minimum Knowledge, Skills, Abilities and Training

• Ability to work independently
• Ability to travel frequently to home visits and community organizations.
• Understanding of SUD as a medical condition and MAT as an effective, evidence-based treatment.
• Understanding that abstinence-based behavioral programs that discourage MAT are not evidence-based.
• Demonstrated ability to work in a multicultural setting with a diverse population and exhibit cultural competency.
• Strong organizational (time management) skills, strong interpersonal skills and the ability to handle multiple priorities.
• Exhibit professionalism and ability to build rapport and maintain relationships with patients/families, internal staff, and community based organizations.
• Nonjudgmental, energetic, positive, harm-reduction approach to assisting patients with SUD.
• Interest/proficiency in working with individuals recently released from incarceration, homeless individuals, and other marginalized populations.
• Ability to communicate with patients clearly, respectfully, and in a culturally appropriate manner.
• Respect for patient confidentiality and privacy.
• Computer proficiency with Google Suite (Docs, Sheets & Slides.)

PREFERRED Qualifications

• Expertise in insurance benefits and exclusions related to treatment and assisting with data collection.
• Bachelors Degree preferred
• Experience with electronic health records
• Experience working in the community in a volunteer or paid capacity related to work within community service agencies, care management or health care delivery.
• Experience with advocacy, community organizing, or other similar work.
• Ability to work a flexible schedule including evening and weekend schedules as program needs arise.
• Ability to communicate in languages spoken in the local community is a plus.