SDOH Health Population Navigator - QIP - FULL-TIME DAYS (24554)

Join Our Team at Bergen New Bridge Medical Center!**

We are dedicated to providing high-quality, compassionate care to our diverse community. As a leading healthcare provider, we offer a supportive and inclusive work environment. If you’re passionate about making a difference and thrive in a collaborative setting, Bergen New Bridge Medical Center is looking for a Patient Navigator.

Job Duties

Contacts patients post discharge per QIP-NJ contractual requirements.

Communicates with patient Care Team members (physicians, behavioral health team and/or other health care providers) to provide patient with integrative care.

Carries out tasks to execute the medical and support service plans including but not limited to guiding patients to appointments and accompanying them when necessary.

Acts as the primary liaison with medical providers to ensure patient adherence to care.

Tracks patient attendance for medical appointments, initiates outreach as well as adhering to missed appointment procedures.

Coordinates treatment plan adherence.

Coordinates deliverables per HORIZON ISC program.

Monitors internal data dashboard to coordinate patient care.

Identifies community resources to address patients' social determinants of health.

Provides referrals to community resources as needed and follow up to ensure referral completion.

Maintains program database of community partners and referrals. Maintains documentation of all patient encounters and completes reporting requirements according to organizational and contractual requirements.

Maintains strict confidentiality in accordance with state and agency policies.

Attends and represents the organization at professional conferences, in-service training, and meetings at the request of or with the approval of supervisor.

Flexibility with covering weekend/evening shifts.

Performs other duties as assigned to support the overall objectives of the department and organization.

• Core Competencies & Experience Needed
• Experience working as a Community Health Worker, care coordinator, or patient navigator serving complex or vulnerable populations
• Strong knowledge of SDOH, including housing instability, food insecurity, transportation barriers, benefits access, and other non-clinical drivers of health
• Demonstrated experience with community-based referrals and resource navigation, including follow-up to ensure successful connections (closed-loop referrals)