Patient Navigator

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Jun 15, 2020


Job Description


To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

Patient Navigator, Patient-Centered Medical Home: Reports to the Manager of livingwellCARES and works in collaboration with PCMH Care Coordinators, physicians, staff and other healthcare professionals. The Patient Navigator is committed to removing the patient's barrier to care by identifying critical resources for patients by navigating through the healthcare system. The Patient Navigator ensures that patients and members are able to access culturally and linguistically appropriate services in a timely and cost effective manner. The Patient Navigator must be knowledgeable about community resources, including financial, educational, social and emotional support services available to patients. The Patient Navigator shall demonstrate cultural competency with respect to populations served and will track patients through completion of referrals to community resources and support goals outlined in care plans to ensure patients overall well-being. Works closely with the patient care team and key collaboratives across YNHHS, NEMG staff, PM staff, hospital based Care Coordinators and Community based resources. The patient care team may include home health and other hospitals/facilities outside the Yale New Haven Health System.



  • 1. Approaches patients, conducts screenings and enrolls eligible patient in patient navigation program carefully explaining to the patient the commitment to the program
  • 2. Provides patient navigation services to patient enrolled in navigation program
  • 3. Attends appointments with patients as necessary. May provide support and advocacy during initial medical visit or when necessary to assure clients' medical needs. Follows up with both clients and providers regarding action plans.
  • 4. Coaches clients in effective management of self-care. Assists clients in understanding care plans and instructions. Motivates clients to be active and engaged participants in their health and overall well-being
  • 5. Facilitates communication and coordinates services between the care team and the clients. Coordinates and monitors services, along with comprehensive tracking of clients compliance in relation to care plan
  • 6. Assists clients in their homes, community, or clinic setting. Helps clients to identify social determinants of health that affect their overall health in addition to developing self-management plans and goals
  • 7. Facilitates client access to community resources including safe housing, food, utility, transportation, and prescription assistance. Additional community resource referrals may include life skills, vocational and educational resources
  • 8. Assists client in utilizing community services, facilitating appointment with community service agencies as well as with completion of applications for program for which they may be eligible
  • 9. Provides patient reminder calls and follow up calls for all appointments and/or referrals to community resources
  • 10. Maintains regular communication with patient throughout the course of their participation in the program through telephone, text messages and email.
  • 11. Travels as needed to client homes, community locations, various agencies, and other outreach destinations
  • 12. Documents all client interactions in electronic database with accurate notes indicating interactions with patients. Documentation may include face to face visits, telephone communication, action plans, and letters mailed.
  • 13. Maintains records of coordination of care, outreach, patient support and/or care management activities for reporting and tracking purposes and completes all documentation
  • 14. Attends and is prepared for scheduled supervision, team meetings, staff meeting or rounds.
  • 15. Seeks additional supervision or consultation as needed and follows through with supervisory directives
  • 16. Builds and maintains positive working relations with client, providers and agency representatives as appropriate to ensure each patient receives comprehensive service.
  • 17. Ability to work collaboratively and effectively with the care team to include other patient navigator, nurse care coordinators,social workers, behavioral specialist, and student volunteers



High School diploma. College degree preferred. Excellent organizational skills and attention to detail. Bilingual Spanish required.


A minimum of 1-3 years' experience in health care or human service setting


Completion of Patient Navigator or Community Health Worker Training Program


*Commitment to the mission of care coordination *Culturally effective capabilities demonstrating a sensitivity and responsiveness to varying cultural characteristics and beliefs. *Demonstrates professional, appropriate, effective, and tactful written, verbal and nonverbal communication with patients, families, medical staff, colleagues, vendors and other departments throughout the continuum of care to promote continuity of care and services and enhance practice image. *Demonstrates positive professional customer service being respectful of all patients, coworkers and providers. *Maintains patient confidentiality at all times. *Participates effectively as a team member. *Proactively acts as patient advocate, responding with empathy and respect to resolve patient concerns and recognizes opportunities for improvement through patient concerns. *Complies with dress code and strives to act professionally in words and actions at all times. *Proactively continues to educate self to provide quality care and improve professional skills. *Must have a valid CT State Driver?s License and own reliable transportation for travel to various network locations.


MMR is required. Varivax (chicken pox vaccine) or evidence of prior chicken pox is required. Hepatitis B (or signed declination) is required for those with potential exposure to blood/body fluids. Tdap and influenza vaccination are strongly encouraged.


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Job Info

Job: 15646

Department: livingwellCARES
Status: Full Time Benefits Eligible
Shift: D
Hours: 40