Massachusetts Jobs

Harbor Health Services is an innovative, growing, mission-based organization that lives, serves and collaborates with our community members to achieve our mission to help individuals reach their full potential through access to local, affordable services that promote health To help further the mission of Harbor, we are looking for a talented Patient Care Navigator to join our Care Team at the Harbor Community Health Center - Hyannis ROLE: The Patient Care Navigator (PCN) works with the patient?s primary care and behavioral health team to address the complex non-medical needs that can negatively affect a person?s health and well-being. The PCN promotes patient-centered comprehensive and coordinated care supporting the patient and their family in navigating medical, social services and legal systems. RESPONSIBILITIES: Establishes trusting relationships with patients and their families. Establishes good working relationships with patients? primary care teams, the Behavioral Health team, MAT team, Client Services, Financial Counselors, Interpretive services, front desk staff, Referrals Department, Call Center, the WIC program, Food Pantry staff, and other clinical specialists so that all team members are empowered to refer to the PCN. Connects patients with concrete community resources, including food resources, subsidized childcare, housing, legal services, financial assistance, IEP?s with school systems and immigration services. Actively listens to patients/clients, analyzes needs and concerns and applies knowledge of health center and community resources to assist in resolving issues. Provides direct assistance to patients with completing paperwork to access resources and benefits when literacy, language or comprehension is a barrier. Assists patients with completing applications and registration forms. Assists patients with navigating services of third-party agencies, such as Inspectional Services, Massachusetts Commission for the Blind and Deaf/Hard of Hearing, MassHealth, Personal Care Attendant Services, Senior Services, Fuel Assistance, Low Income Housing applications, SNAP benefits, Transportation Services and homeless shelters. Assists patients with complex medical needs coordinate appointments, assists with scheduling transportation, and with any other barriers for patients getting to their appointments, including assisting with appointment reminders. Connects patients to and assists with accessing Social Security Disability and Department of Transitional assistance benefits, including support with the application process, interview preparation, completing needed paperwork and follow up. Actively participates in complex care team meetings, MAT team meetings, and care conferences at the Behavioral Health department meetings, and other team meetings as assigned. Coordinates services to ensure quality standards are met for Accountable Care Organization. Documents and manages clear care plans, goals and referrals in EPIC Electronic Medical Record (EMR). Maintains updated information on contacts with community partners/agencies. REQUIREMENTS: Bachelor?s degree in Social Work, Psychology, Human Services or related field 2 years of experience working in a community-based setting preferred Current BLS (Basic Life Support for Healthcare Providers) Certification Written and oral fluency in English required, fluency in Portuguese or Spanish preferred Experience working in a multi-cultural setting Knowledge of Microsoft Office 365 proficiency including Word, Excel and Outlook; basic computer skills, experience using EMR (EPIC) preferred. Ability to initiate and maintain positive working relationships with Harbor staff and staff at other organizations. Knowledgeable with the local community resources. Good communication skills. Must be able to travel in a timely manner to other HHSI sites and other outside agencies as needed