DSNP Care Navigator

DSNP Care Navigator

Field- Ventura County, CA

Schedule: Mon-Fri 8-5pm PST

Hourly Rate: $27.00 / Hour

Job Details:

• Completes telephonic calls and in-person home and field visits to conduct the HRA and associated assessments with DSNP members. Works with the member to develop an individualized care plan (ICP) and with interdisciplinary care team (ICT) to develop and assess health interventions on-going.
• Responsible for the time sensitive processes for initiating cases, managing referrals to the department, appropriate documentation, routing of information, performing computer data input, faxing, emailing, filing of confidential member information, and maintaining logs of activity, etc.
• Conducts telephonic outreach calls to members/caregivers regularly and evaluates and documents their progress towards their healthcare goals. Sets up provider/specialist appointments and follow up on treatment plans. Assess changes in member status that warrant additional HRA or ICP review and updates.
• Transitional Care Services: Provides member and caregiver support, coordination, education and advocacy during all in-patient care stays and transitions between care settings ultimately to home through the entire episode of care.
• Engages members as appropriate to participate in the CM/Disease Management and other specialized care programs by reaching out and promoting the programs to address member’s unmet needs.
• Handles the incoming and outgoing calls to members/caregivers and providers to coordinate care as identified in the care plan.
• Initiates follow up calls to members to administer screenings or confirm linkage to appropriate resources. Creates referrals and performs follow-up with service providers and community partners.
• Performs and Supports Care Coordination, Case Management, and System Navigation for Medicare and MediCal services.  This includes Participating in care coordination and case management, conducting assessments, making referrals and providing follow-up, coordinating transportation to services and helping address barriers to services. Linking member to community resources to address the Social Determinants of Health (SDoH) of the member.
• Reviews member cases and prepares case presentations for internal Interdisciplinary Care Team (ICT) meetings in collaboration with the CICM CM.
• Advocating for Individuals: Advocating for the needs and perspectives of the member and caregiver. Connecting to resources and advocating for basic needs (e.g. food and housing).
• Attending regular staff meetings, on-site monthly training and other meetings as requested.  Managing assigned caseload.
• The position is responsible for ensuring the plan meets the contractual and regulatory requirements, timelines and Quality Measures by maintaining accurate documentation and following up with the member and provider as needed.
• Perform other duties as assigned.

Job Requirements:

• High School Diploma/or High School Equivalency Certificate.
• At least 3 years of experience as a health navigator, community health worker, peer support worker, outreach work or working in a community setting and providing health education for chronic conditions, or equivalent.
• Associate or Bachelor’s degree in health care or social service-related focus preferred.
• Successful completion of a Community Health Worker formal training program from a college or other education institution preferred.
• Training in health education for chronic diseases, motivational interviewing is desirable.