Patient Navigator – Social Worker

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This position is responsible and accountable for assessing the Social Determinants of Health for designated patient populations to address and eliminate disparities resulting improvement of service delivery.  Works in collaboration with the Patient Centered Medical Home (PCMH) Care Team to facilitate and coordinate the patient’s treatment plan.

Duties and Responsibilities

  • Prepares PCMH Care Teams and individual patients for scheduled visits by conducting individual EHR reviews and patient pre-visit outreach contacts.
  • Develops comprehensive, collaborative Care Plan, based on Provider treatment plan, evidence based chronic care guidelines, and patient/family goals for patients with chronic conditions and/or recent care transitions to promote treatment acceptance and adherence to Provider recommendations and instructions.
  • Monitors and facilitates the transition of patient care through various levels across the healthcare system.
  • Accepts referrals and manages Provider patient panels.
  • Reviews system-related tasks and email instructions throughout the day for management of daily responsibilities to follow all assigned patient cases effectively and thoroughly through to completion.
  • Serves as a supportive resource and community referral resource within the practice.
  • Uses Electronic Health Record (EHR) system, tracks navigation services, records all patient encounters, and contributes to clinic tracking workflows.
  • Adheres to clinic departmental policies and procedures, which include accreditation standards, Trauma Informed Care, Patient Safety initiatives, Patient Rights, and Health Insurance Portability and Accountability Act (HIPAA) Privacy standards.
  • Population specific risk management by registry and referral including:
    • Direct patient care related to patient navigation duties to be performed via in-person, telephonic, and/or electronic communication.
    • Provide individual patient/family education and self-management support that is appropriate based on language, cognitive abilities, literacy level, learning style, cultural norms, patient preference, readiness for change and resources available.
    • Provide individual or group education regarding health conditions, self-management, or other population specific topics of healthcare.
    • Communicate changes in patient’s status appropriately with the Care Team.
    • Identify and remove barriers when treatment goals are not met, care plan is not followed, or important appointments are missed.
    • Tracks program specific and patient-level quality measures to develop intervention approaches to improve data driven outcomes.


  • Experience in community health or social services experience required.  Community Health Worker (CHW) certification or social work degree highly preferred.
  • CPR certification, or willingness to attend CPR class and obtain certification required.
  • Must have dependable transportation and excellent attendance.
  • Have proven expertise in healthcare processes, critical thinking, and problem-solving.
  • Utilizes organization, prioritization, attention-to-detail, and follow-through.

This position is full-time Monday – Friday, 37.5 hours per week with no evenings weekends or holidays.

This position pays $20.50 per hour and offers a competitive benefits package including Health, Dental, Vision and Life Insurance, a matching retirement plan, Employee Assistance Program, 11 paid holidays and generous PTO.

Please provide your salary requirements when you apply to be considered for an interview for this position.

Neighborhood Health Association (NHA), a Federally Qualified Health Center (FQHC), is the largest community health center system in Northwest Ohio with partnerships that include ProMedica, Mercy Health, and University of Toledo Medical Center. NHA has grown from a single location in 1969 to 12 medical and dental clinics throughout Lucas County. Today we operate multiple health centers including pediatrics, adult medicine, dental services, health care for the homeless, women’s health center, senior centers, and a full-service pharmacy with lab services on site.

For more than 50 years, NHA has placed a strong focus on prevention and empowering individual responsibility in managing their health care and overall well-being. Our services are acutely responsive to the needs of everyone throughout the communities we serve, providing excellent care and the best health practices.

Our Mission: Through our exceptional health care services, we empower and educate, aggressively working to eliminate health care inequities, while supporting personal responsibility for one’s own health regardless of the ability to pay.

We are a drug free workplace, and an Equal Opportunity Employer