The Complex Care Access Navigator provides adjunctive support to the Complex Care Case Manager and a caseload of MCC patients with “mild to moderate” (M2M) behavioral health concerns and other complex medical conditions and psychosocial needs. Complex Care Access Navigator will work to fulfill the goals established by the Whole Person Care (WPC) program: to improve the wellbeing of Marin’s Medi-Cal population who are experiencing complex medical conditions and those who are homeless or precariously housed. Additionally, the Complex Care Access Navigator will ensure that “high-risk” Medi-Cal beneficiaries with barriers to care get the support they need to access care and manage their social determinants of health. The Whole Person Care program adheres to the tenets of Person-Centered, trauma informed, and Housing First philosophies of care. To this end, the Access Navigator provides logistical and intrapersonal support to a caseload of 30 patients with the goals of minimizing barriers to care, improving health outcomes, and helping patients develop the ability to manage their needs with greater independence. Working collaboratively with Complex Care Case Manager, primary care, behavioral health, nursing and members of the larger care navigator team, the Complex Care Access Navigator works as a member of an integrated team of professionals to provide patient-centered, outcome driven care in the context of the MCC medical home and Whole Person Care.
Implement comprehensive care plan as determined by Complex Care Case Manager;
Assist Patients to complete necessary forms/applications;
Teach independent living skills as needed;
Work with Patients to address social determinants of health (SDOH)
Provide information and referrals to community resources and stay updated on current resources;
Track referrals and provide follow-up to ensure service delivery;
Maintain communication with Patients to ensure that patients obtain necessary labwork and prescriptions;
Participate in shared visits with MCC medical providers and specialty providers.
Consult/coordinate with interdisciplinary care team, including behavioral health, care navigation MAs, nursing, and medical providers;
Document all Patient interactions and services using MCC’s electronic health record AND WPC tracking system;
Attend WPC meetings as needed
Timely and accurate reporting of data as requested to MCC and WPC
May travel between clinics or meet Patients in the community as needed
Attend behavioral health meetings, care navigation meetings, medical provider meetings, all-staff meetings, as scheduled
Provide frank and considered opinions regarding case management services and quality improvement measures;
Provide guidance and consultation to larger care navigation team regarding issues relevant to WPC program;
Provide services to satellite clinics as needed; may be asked to work variable schedule during extended-hour clinics (e.g., 10am-7pm on one or more days).
Other duties may be assigned.
Must be fluent in English with the ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports and business correspondences in English. Must have the ability to effectively present information and respond to questions from clients, customers, and the general public in Spanish. Must be able to conduct clinical assessment interviews and case management interventions with patients in Spanish.
To perform this job successfully, an individual must be computer literate and knowledgeable in Microsoft Office software programs, and how to conduct searches on the Internet.