Child & Family Services
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Required: Bachelor Degree in Gerontology, Social Work, or related field with Elder experience.
The Peer Navigator (PN) is a problem solver, teacher and peer of the Member with Neighborhood Health Plan who has intimate knowledge of available community resources. They have the ability to link Members with a complete array of resources that assist Members to overcome barriers to proper health care. The PN has the skills and experience to assist Members to be responsible, accountable and self-sufficient; and to relate to Members and serve as their mentor to coach to achieve desired outcomes. Peer Navigators must be able to function as an extension of Neighborhood and, at the same time, be an advocate for the Member. Specifically, the PN shall perform the following activities:
· Conduct initial outreach attempts to Members within five (5) days from date of referral.
· Outreach to Members via telephone, home visits, and or other appropriate means of communication.
· Assist Members in identifying and accessing community resources.
· Assist Members with the Long-Term Services and Supports (“LTSS”) application process.
· Secure concrete basic needs, e.g. food and clothing, when needed.
· Assist/train Members with obtaining, scheduling or rescheduling health care appointments and/or transportation to those appointments.
· Link Members to ongoing social support mechanisms or “social networks,”e.g. groups, neighbors, associations.
· Provide mentoring and/or coaching to Members so they may learn to self-identify and access community resources independently.
· Member mailings as needed to reach members for a failed outreach as well as educational and resource related information.
· Advocating for the Member when needed.
· Serve as a role model to practice responsible health behaviors.
· Communicate with case management staff, updating them on the Member’s progress, or lack thereof and identify any potential barriers.
· Document all interactions and interventions regarding members in Acuity, the care management software system.
· Continue to engage with the Member until the goals of the Interdisciplinary Care Plan (“ICP”) are met.
· Collaborate with Neighborhood in multidisciplinary rounds as needed and participate in regularly scheduled Case Conference Rounds.
· All member related documentation shall be in Acuity. The documentation includes all member outreach attempts, member contacts and engagement activities and as well as interactions with the care team.
· Documentation related to quality of care issue follow up shall be entered into Acuity within three (3) business days of the issue being identified.
· Documentation addendums or clarifications shall be entered into Acuity within three (3) business days of the date of the error being identified. *
Engagement with Members to link them to the appropriate resources. Providing ongoing support and education through:
· Collaboration with appropriate Neighborhood staff.
· Connection to behavioral health resources, including education on maintaining a relationship.
· Connection to physical health resources, including education on maintaining a relationship.
· Connection to community resources, including education and assistance with application processes for social services, e.g. food and housing assistance
· Connection to dental resources.
· Connection to Neighborhood benefits and services, including, but limited to, transportation, interpreter services.
· Other interventions within the scope of a PN, as needed, to assist Members in overcoming barriers to accessing appropriate health care resources.
· Bachelor Degree in Gerontology, Social Work, or related field with Elder experience.
· Valid driver’s license required.
· Bilingual, Spanish or Portuguese desirable but not required.
· Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.