Long Island Association for AIDS Care
  • Hauppauge, NY, USA
  • $35,000.00
  • Salary
  • Full Time

PATIENT CARE NAVIGATOR

Hauppauge, NY Full-time Position

TARGETED CASE MANAGEMENT PROGRAM

JOB PURPOSE

To work collaboratively with Health Home Care Coordinators/Care Technicians to provide care coordination services to clients who are diagnosed with multiple chronic medical and behavioral health issues.

BASIC FUNCTION

As part of the care coordination team the patient care navigator performs duties to support the goals and objectives of the Health Home; to prevent or reduce unnecessary emergency room visits and hospitalizations. Clients with active Medicaid are served in Nassau, Suffolk, and Queens Counties.

SPECIFIC RESPONSIBILITIES

  1. Travel to numerous locations either to engage/enroll clients or provide support to the Health Home Team.  Meet with clients in their homes, physician/provider offices, and other public places to conduct health needs assessment and other required assessments and documents, according to the Health Homes timeframes.
  1. Work collaboratively with a team that includes Care Coordinators, Care Technicians, clinical providers, etc. to develop and maintain client centered care plan goals.
  • Determine potential barriers to care
  • Obtain mutual agreement on the medical/behavioral health goals and how to achieve them;
  • Educate and explain how to follow the care plan tasks; and
  • Consult with client's consented family, friends and other identified support systems regarding what they need to do to assist in helping client meet his or her goals.
  1. Ensures active Medicaid eligibility is in place prior to and during services; advocacy at the local government unit may be required.
  1. Follows up with clients after discharge (emergency room, hospitalizations, inpatient rehabilitation, nursing home, etc.
    • Identify and reconnect ongoing service supports (provider referrals)
    • Support client in medication adherence, provider appointments,
    • Health care system navigation, etc.
  1. Maintains communication with Health Home team, to locate client(s) who are lost to services. 
  2. Establishes effective, trusting working relationships with clients, healthcare teams, clinical providers and create professional community linkages.
  3. Reaches out to community partners to identify gatekeepers for the purpose of providing outreach to potential clients and becomes a reliable source of information for patients.
  4. Seek current information about available patient resources.
  5. Maintain current disease referral information for clients.
  6. Advocating for, empowering, and supporting clients while they learn to self-navigate.
  7. Encouraging clients to become advocates for their own care; and modeling behaviors for clients in regards to scheduling appointments, arranging transportation, communicating medical concerns with specialists.
  8. Facilitating and coordinating client care to ensure timely diagnoses and treatment.
  9. Maintaining communication with clients and the healthcare team.
  10. Contacting patients who have a barrier for missing appointments.
  11. Attend and participate in scheduled case review with Care Coordinator Team.
  12. Use of mobile devices to access Electronic Health Record (EHR system).
  13. Document all phone contacts (attempted and successful), engagement letters, scheduled and unscheduled home visits, referrals, case conferences and face-to-face meetings.
  14. Assure client information is kept confidential at all times.
  15. Reports to and meets with supervisor on a regular basis.
  16. Attends staff development and trainings as required and assigned by supervisor.
  17. Performs other duties as required and assigned.

QUALIFICATIONS

Bachelor's degree preferred. Associate's degree in health/human service field and 1 year of qualifying experience.

Bilingual preferred. Excellent oral and written communication skills required. Computer literacy including Microsoft Office required.

 

LIAAC is an equal opportunity employer and will consider all applicants for all positions equally without regard to their race, color/creed, religion, gender, gender identity, sexual orientation, national origin, citizenship, genetic information, domestic violence victim status, age, marital status, veteran status or any disability as provided in the Americans with Disabilities Act, any real or perceived disability (including HIV status), or any other characteristic protected by law.

Long Island Association for AIDS Care
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