Care Navigator
$47K - $50K/yr
CARE NAVIGATOR ABOUT Impact Primary Care Network (IPCN) and Impact Health Impact Primary Care Network is a physician-led clinically integrated network (CIN) that is leading a new approach to ...
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Care Navigator
$47K - $50K/yr
CARE NAVIGATOR ABOUT Impact Primary Care Network (IPCN) and Impact Health Impact Primary Care Network is a physician-led clinically integrated network (CIN) that is leading a new approach to ...
Job description
CARE NAVIGATOR
ABOUT
Impact Primary Care Network (IPCN) and Impact Health
Impact Primary Care Network is a physician-led clinically integrated network (CIN) that is leading a new approach to delivering whole-person care in Western North Carolina (WNC). IPCN is deeply invested in patient health and the health of this rural region. The care management platform and services are designed to seamlessly integrate social health support with clinical care to improve patient health outcomes. IPCN supports primary care practices participating in innovative population health initiatives like NC Medicaid’s Managed Care Plans and Healthy Opportunities Pilot (HOP).
IPCN was founded by Impact Health, a nonprofit that leads innovative strategies to bridge social and clinical systems of care in Western North Carolina and across the nation.
IPCN is the nonprofit clinical arm dedicated to integrating social and primary care through high-quality care management across Western North Carolina.
When you join IPCN, you join a network focused on achieving key healthcare transformation goals, including:
ABOUT
Impact Primary Care Network (IPCN) and Impact Health
Impact Primary Care Network is a physician-led clinically integrated network (CIN) that is leading a new approach to delivering whole-person care in Western North Carolina (WNC). IPCN is deeply invested in patient health and the health of this rural region. The care management platform and services are designed to seamlessly integrate social health support with clinical care to improve patient health outcomes. IPCN supports primary care practices participating in innovative population health initiatives like NC Medicaid’s Managed Care Plans and Healthy Opportunities Pilot (HOP).
IPCN was founded by Impact Health, a nonprofit that leads innovative strategies to bridge social and clinical systems of care in Western North Carolina and across the nation.
IPCN is the nonprofit clinical arm dedicated to integrating social and primary care through high-quality care management across Western North Carolina.
When you join IPCN, you join a network focused on achieving key healthcare transformation goals, including:
- Better patient experience
- Improved population health
- Lower healthcare costs
- Improved provider satisfaction
- Health equity
Position Summary
The Care Navigator is a key member of the IPCN care management team, supporting population health initiatives for managed Medicaid members. Collaborating closely with Nurse Care Managers, the Care Navigator identifies and addresses social determinants of health (SDOH), connects patients to community-based resources, and supports transitions of care (TOC) following hospital and emergency department discharges. With appropriate clinical supervision, the Care Navigator provides basic health coaching for patients with chronic conditions, conducts telephonic outreach, and engages directly with patients and primary care practices to promote timely follow-up care, improved health outcomes, and enhanced patient experience. This role serves as a liaison among patients, network practices, community agencies, and the broader care team to ensure coordinated, patient-centered care.
Essential Responsibilities and Duties
Social Care Navigation
- Develop, maintain, and utilize extensive knowledge of internal and external social and medical resources in WNC.
- Identify and assess social determinants of health (SDOH) needs through patient outreach, screening tools, and collaboration with health plans, providers, and clinical teams
- Connect patients to appropriate community-based resources (e.g., food assistance, housing support, transportation, personal safety, social services) and support follow-through on referrals
- Utilize NCCARE360 or other referral platforms as appropriate
- Develop and maintain appropriate care plans for SDOH needs by creating SDOH-specific SMART goals and monitoring progress toward completion of identified goals
Clinical Care Navigation
- Conduct post-hospital and emergency department discharge outreach (TOC) to ensure patients understand discharge instructions and receive timely follow-up care
- Coordinate with primary care practices to schedule follow-up appointments and address barriers to care
- Support IPCN care team with referrals and individualized care planning for addressing medical, social, and emotional needs
- Provide basic health coaching and education for patients with chronic conditions (e.g., diabetes, hypertension, asthma), under the clinical supervision of Nurse Care Managers
- Escalate clinical concerns, complex needs, or barriers to Nurse Care Managers, supervisor, or other appropriate team members
- Understand and support the achievement of IPCN-identified Quality goals
Engagement
- Perform telephonic outreach to patients to assess needs, support engagement, care plan adherence, and self-management goals
- Spend scheduled time embedded in primary care practices within the IPCN Network to collaborate with practice providers and staff and meet patients face-to-face when appropriate
- Serve as a liaison among patients, IPCN care team, primary care practices, and community agencies to promote coordinated care and healthy patient outcomes
- Support population health initiatives and quality improvement efforts related to care transitions, SDOH, preventative health, chronic condition management, and patient engagement
- Participate in team meetings, training, and ongoing performance improvement activities as assigned
Technology and documentation
- Competently utilize assigned technology platforms (e.g., Innovaccer, various practice electronic health records (EHR), NCCARE360)
- Document patient interactions, assessments, care plans, referrals, and outcomes accurately and timely in designated care management or electronic health record systems
- Develop and maintain care plans for SDoH needs by setting clear goals, developing structured approaches to support SDoH needs, and collaborating with clients, other health care providers, and HOS personnel to ensure resource utilization.
- Provide technical assistance to others around SDOH screening, referrals, and using NCCARE360
- Maintains an appropriate working knowledge of applicable Federal, State, and local laws and regulations, as well as payor agreements, and Impact Health and IPCN policies
Qualifications are a guiding light and not all-encompassing of what Impact Health considers throughout the selection process. And while specific certifications are outlined below, Impact Health encourages candidates to include a cover letter to share how their lived experience, education, and work experience combine to support this role.
Required Education/Certification
- Associate’s degree in social work, or related field, with required work experience
Preferred Education/Certification
- Bachelor's degree in social work or a related human service field
Required Work Experience
- Associate’s degree requires two years’ experience in direct client services, community-based programs, relevant clinical or social service settings, or eligibility screenings
Preferred Work Experience
- Proven delivery of quality customer service
- Medical/clinical setting experience
- Experience with diverse populations.
- Experience partnering with individuals and families with complex needs
- Knowledge of NCCARE360
Knowledge, Skills, and Attributes
- Knowledge of needs and issues related to social determinants of health
- Excellent customer service and problem-solving abilities
- Effective communication skills and etiquette – both verbally face-to-face and by phone, and written by email, text, and record keeping
- Displays empathy and patience to consumers and coworkers
- Understanding medical documentation and electronic medical records
- Demonstrates a high degree of cultural awareness and sensitivity when working with vulnerable populations
- Highly responsible, organized, and accountable
- Understands and protects patient privacy as it relates to HIPAA
- Projects a positive, service-oriented attitude and desire to enhance the quality of assigned tasks
- Highly adaptive and able to perform well in an evolving team environment
- Bilingual is a plus
WORKING ENVIRONMENT
This position will be a hybrid role, split between working from a home office and primary care practices with some scheduled in-office time. Work schedules and locations may shift from time to time to accommodate practice assignments and team holiday coverage.
Additionally, this position requires a home office that meets Health Insurance Portability and Accountability Act (HIPAA) home office compliance standards.
The job requires weekly travel to assigned primary care locations, including driving to multiple sites. Applicants must be committed to living within and performing hybrid work in the 18-county WNC region served. Applicants must have a valid North Carolina driver’s license and must have reliable access to their own vehicle. Mileage and other approved travel expenses will be reimbursed in accordance with the organization’s travel policy.
WORKING CONDITIONS
This position requires frequent sitting, standing and occasional walking; occasionally lifts objects weighing up to 10 pounds. This position requires manual dexterity sufficient to operate phones, computers, and other office equipment. This position requires the visual ability to work in front of a computer screen for prolonged periods. This person must speak clearly using the English language to accurately convey information and be able to hear at normal speaking levels both in person and over the telephone. The employee must be able to receive and understand written and oral communication and give written and oral instructions.
WHAT WE OFFER
Salary starting at $47,000.00 – 50,000.00.
The starting salary is commensurate with experience, which will be vetted during the interview process.
All full-time team members can take part in a broad range of competitive benefits, including:
- 100% employer-paid insurance
- 4 weeks of PTO
- 1 week of winter break
- 10 paid holidays
- 6% match for 401K
- Home office set-up stipend
OUR COMMITMENT TO EQUITY AND INCLUSION
Impact Health is committed to diversity, equity, and inclusion in our work and on our teams. We know that the rich diversity of perspectives and wisdom that is imperative to our purpose can only come from a wide variety of origins and life experiences. We strongly believe that creating a workplace where all team members thrive is critical to fulfilling our purpose in the communities we serve, and we intentionally recruit, develop, and retain the most talented people from a diverse candidate pool.
Qualified candidates are urged to apply and will receive consideration for employment without regard to race, color, ethnicity, sex, age, national origin, religion, sexual orientation, gender identity and/or expression, status as a veteran, and basis of disability or any other federal, state, or local protected class.