Social Care Navigator bei Virginia Garcia Memorial Health Center

At Virginia Garcia Memorial Health Center, we welcome diversity; we encourage, uplift, and are honored to serve people who have been historically underrepresented and underserved. Our mission is to provide high-quality, culturally appropriate healthcare to low-income residents of Washington and Yamhill Counties, with a special emphasis on seasonal and migrant farm workers and others with barriers to receiving healthcare. We strive to provide an inclusive environment that welcomes and values the diversity of the people we employ and serve.

Job Summary: The Social Care Navigator functions as an integral part of the BHMH Services Department's Primary Care integration to assess and address patient's needs as related to their resilience/self-determination, ability to access outpatient services and social determinants of health. This individual provides skills training and case management services and links patients to needed community resources through their work on medical and BHMH teams to coordinate services and care that address their medical, mental health and/or other psychosocial needs. They also work with the Primary Care Teams to outreach and work with complex health and/or psychosocial needs of patients and those who are high utilizers of hospital and Emergency Department services. This position may supervise students in disciplines appropriate to the Navigator's educational background and qualifications.

Essential Duties and Responsibilities:

·         Function as an integral part of the BHMH Team attending huddles, team meetings and coordinating services with team members for complex patients.

·         May work with primary care medical teams, attending huddles and team meetings and connecting with team members as needed to assess patient's needs and connect them to resources in the medical and social services community.

·         Assess patients' social determinants of health and health literacy, utilizing screening tools and questionnaires to assess the patient's living situation, health literacy, safety, cognitive abilities or status, history of or current substance misuse, physical, mental or sexual abuse, intimate partner violence, and mental health needs.

·         Gather and maintain information, resources and accessible services of community agencies, local and state organizations, acting as a liaison with outside agencies.

·         Build a supportive relationship with patients to improve patients' utilization of necessary and appropriate primary care, mental health, and social services, in order to improve the patients' health status and health outcomes.

·         Use motivational interviewing to assess and positively affect the patient's level of engagement in their care and confidence in their ability to carry out a self-management plan.

·         Participate with the team in developing a comprehensive care plan.

·         Communicate with the primary care team, documenting all contacts with patients in the

EHR (EPIC) in a timely manner and communicating in person or by <