Community Health Worker (Navigator)

Who We Are Neighborhood Health Center is a non‑profit organization local to Portland, OR serving underserved patients in the areas of primary care, internal medicine, dental services and more. Our patient‑centered approach to care honors the unique needs and circumstances of each individual patient. NHC sees people, not problems, and recognizes that the time spent as a patient in a doctor’s office is only one factor in a person’s overall health. Our leading‑edge, integrated clinical teams work in partnership with patients, their families, and the communities we serve to provide whole‑person care, prevention, and ongoing support. Why work with us? We are a non‑profit organization, passionate about providing the underserved population with medical and dental services across the greater Portland area, committed to making a difference daily. We offer our employees a competitive compensation and benefits package which includes 20 days of PTO (based on full‑time employment), 9 paid holidays, health/dental/vision insurance, quarterly wellness reimbursements, generous 401(k) retirement plan with employer match, employer‑paid disability insurance, EAP and life insurance. Our employees voted NHC a Top Workplace in 2020, 2021, 2022, 2023, and 2024. Job Title: Community Health Navigator Department: Behavioral Health Reports To: Manager of Behavioral Health Work Type: On Site – This position includes travel to various clinics & community spaces in the Portland Metro Area Classification: Full‑Time, Non‑Exempt Language Differential: Eligible Job Summary Community Health Navigators (CHN) are non‑clinically licensed health care staff members who are frontline public health workers deployed in clinical and community care settings to improve the social health of Neighborhood Health Center (NHC) patients in the communities we serve. Navigators act as the quarterback of the care plan for members who have unmet social, medical, and behavioral needs. They work with patients, families/caregivers, medical providers, and community partners to coordinate care and services across the continuum. Navigators are highly trained communicators and subject matter experts, skilled in Motivational Interviewing and responsible for ongoing community and NHC resource knowledge. Through building strong relationships and trust with patients and their families/caregivers, they can activate clinical care plans, identify patient‑centered goals, and connect members to needed community resources to improve health outcomes and reduce total cost of care. The goal of the patient navigators is to help our members with real‑life issues that create barriers to their total health goals. Additionally, patient navigators outreach to our post‑behavioral health hospital discharge ready paneled patient population, and patients with recent emergency room visits for primary reason being behavioral health. Essential Job Duties Assist patients with social issues like houselessness, substance abuse and mental health resources, and food insecurity resources, and assess need through social determinants of health (SDOH) screenings. Assist patients with organizing their medical care by making follow‑up appointments, filling prescriptions, and connecting to specialty health as needed. Support patients through providing resources to connect to benefits and public assistance programs; examples are health insurance, food stamps, and other resources as needed. Initiate a follow‑up call to patients who have been discharged from the emergency department or hospital following behavioral health crises within 24‑48 hours post‑discharge. Assess and offer mental health resources, SDOH screening, care coordination, and scheduling with behavioral health and clinical pharmacy post‑hospital or ED visits. Build rapport with patients to engage them in their care plan, offering encouragement and guidance in addressing their behavioral health needs. Collaborate with the primary care team, Behavioral Health Consultants (BHCs), and external providers to ensure smooth transitions of care and continuity of services for patients’ post‑discharge. Assist patients in scheduling follow‑up appointments with behavioral health providers, primary care physicians, or other relevant services. Connect patients to community resources that address social determinants of health (e.g., housing, food, transportation) that may impact their mental health or substance use recovery. Identify patients at risk for further crises and elevate cases to the care team or appropriate emergency services as needed. Maintain accurate records of patient interactions, interventions, and referrals in the electronic health record (EHR) system. Conduct regular follow‑ups with patients to assess their progress, adherence to care plans, and any new or ongoing needs. Communicate all care and coordination activity, risks and care plans using standard documentation, information technology and care coordination tools in the electronic medical record. Be the system coordinator and point of contact for patients and families. May assume advocate role on the patient’s behalf to ensure approval of the necessary services or accessibility of needed resource(s) for the member in a timely fashion. Create collaborative relationships with staff across departments within Neighborhood Health Center, and externally, to promote collaboration and multi‑system coordination. Increase access to health and health‑care services through innovative health models, virtual care strategies and collaborative community partnerships. Apply motivational interviewing and patient‑centered approaches to address concerns around barriers to healthcare needs to improve the care experience and motivate patients to meet their health goals. Ability to work independently with accountability and exercise sound judgment, discretion, and professionalism at all times. Good organizational and time‑management skills. Other duties as assigned. Ability to travel up to 80% of the time and independently meet with patients in the clinic, home, or community‑based setting. Ability to work across various primary care clinics within NHC. Participate in on‑site events, clinics, and outreach initiatives as assigned. Qualifications Education and/or Experience Required Qualifications Minimum two (2) years of experience in a community/clinic‑facing role, addressing social determinants of health in a healthcare setting, navigation across health systems, and post‑hospital/emergency room visit outreach is required. High School Diploma or General Education Development (GED) is required. Completion of the approved state certified THW/CHW is required. Preferred Qualifications Associate’s Degree in public/community health or healthcare related field or two (2) years of experience in a directly related field. Motivational Interviewing certification, Mental Health First Aid certification, and Trauma Informed Care training, or other trainings as assigned. Bachelor’s degree in public/community health or healthcare related field. Bilingual in Spanish. Prior experience working with people experiencing homelessness, mental illness, and/or substance use. License and Certification Requirements Completed and Active Certification as Traditional Health Worker in the State of Oregon: CHW or Peer Support Specialist in Oregon is required. Knowledge, Skills, Abilities & Behaviors Experience providing case management (or similar) services. Ability to work on multi‑disciplinary teams. Experience working with ethnic, racial, economic, broad range of ages, and sexually diverse populations. Ability to demonstrate flexibility and to adapt when faced with internal or external barriers, or when faced with differing points of view. Demonstrated computer proficiency using Microsoft Office (Word, Excel, Outlook) and working knowledge of the internet. Demonstrated excellent written and oral communication skills. Demonstrated ability to effectively collaborate with community stakeholders. Reliable transportation. Verbal and written fluency in English. Work will be in compliance with Federal and State administrative rules. Working Conditions This position is typically with a 40‑hour per week, with hours that may vary. While performing the duties of this job, the employee is occasionally exposed to toxic chemicals and bodily fluids. The noise level in the work environment is usually moderate to loud, based on patient volume. As a result of high patient volume, this position experiences stressors that come along with a fast‑paced environment. Must be able to travel during the workday and/or cover at other locations as needed. Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Lift, move, push, or pull objects/equipment/supplies weighing approximately 20‑25 pounds up to 40‑50 pounds. Use full range of body motion; walk swiftly, stand, move, stoop, reach with hands and arms and bend. Sit for extended periods of time or stand and move for extended periods of time. Use sufficient manual dexterity in order to safely perform various skills and techniques or manipulate equipment. See minor details from a distance, and differentiate between colors, shades, brightness textures and depth. Use hands and fingers to handle, control or feel objects tools or controls. Repeat the same movements when entering data. Speak clearly so listeners can understand. Hear and understand the speech of another person. Read from a computer screen for extended periods of time. Employee Must Frequently Use the electronic health record (EHR) system to document all patient interactions, assessments, and referrals. Collaborate with Behavioral Health Consultants, primary care physicians, and community partners to coordinate patient care plans. Conduct follow‑up calls and in‑person visits with patients as part of care coordination. Travel up to 80% of the time to meet patients in various community settings. Participate in on‑site events, clinics, and outreach initiatives as assigned. NHC is an Equal Opportunity Employer. We celebrate differences in the workplace and do not discriminate in employment opportunities or practices on the basis of race, color, religion, gender (sex), national origin, age, veteran status, sexual orientation, gender identity, disability, genetic information or any other characteristic protected by law. Neighborhood Health Center Employment Offers are contingent on successful completion of reference checks, background checks, drug screening for illegal substances, Tuberculosis, and any position specific credentialing or licensure requirements. #J-18808-Ljbffr Neighborhood Health Center