Description

SHENANDOAH VALLEY WESTMINSTER-CANTERBURY

POSITION DESCRIPTION

TITLE: Care Navigator                     DEPARTMENT:  Social Services

RESPONSIBLE TO:   Director of Supportive Services

JOB SUMMARY:                The Care Navigator helps Independent Living Residents coordinate and navigate their care across the care-continuum at SVWC. The position serves as a resident-centered resource who promotes informed decision-making, continuity of care, and timely access to appropriate medical, social, and supportive services.

REQUIRED EDUCATION, EXPERIENCE, SKILLS, LICENSURE:

Master of Social Work degree required.
        Experience in health care navigation, case management, social work, or a related medical field preferred.

        Experience or knowledge of managed-care pre-authorization processes preferred.

        Highly motivated, energetic, and able to work both independently and under the direction of the Director of Supportive Services.  

        Multi-tasker with excellent communication skills.

        Case Management certificate and UAI certification or ability to obtain.

Strong interpersonal and communication skills and the ability to work effectively with a wide variety of individuals within the facility as well as people from the outside community.
Interviewing and social work evaluation skills.
Ability to maintain emotional stability to cope with human suffering, emergencies, and other stresses.
        Must be able to use, operate, and interpret information from various online platforms, insurance portals, and hospitals’ EHR.

JOB REQUIREMENTS, STANDARDS, AND COMPLIANCE:

        Support the Mission and purpose of Shenandoah Valley Westminster-Canterbury (SVWC). Perform duties in a manner consistent with SVWC’s mission and vision.

        Follows and supports the policies and procedures established by SVWC and supports Board of Trustees and Administration.

        Present a professional, supportive, and caring image towards residents, visitors, and fellow team members. 

        Must comply with all required employment training and annual TB Screening as required by Virginia State Licensure.

        Must complete annual mandatory compliance training required by Virginia State Licensure and all other mandatory documentation required by other regulatory agencies and/or by SVWC.

ESSENTIAL JOB FUNCTIONS & RESPONSIBILITIES:

Independent Living Care Navigation 

        Serve as a primary resource for Independent Living residents and, when authorized, their responsible parties regarding health care options, services, and resources. 

        Meet with residents to identify health care navigation needs, clarify priorities, and develop resident-centered plans for accessing appropriate services.

        Help residents utilize the SVWC care continuum, including clinic, wellness, rehabilitation, and higher-level care resources. 

        Help residents navigate local health systems, including hospitals, emergency departments, primary care practices, specialists, outpatient services, home health agencies, and hospice organizations. 

        Assist residents with coordinating appointments, referrals, diagnostic services, follow-up care, transportation, and the exchange of information among providers, as appropriate. 

        Support residents before and after hospitalization, emergency department visits, procedures, and significant changes in health status to promote continuity of care and understanding of follow-up recommendations. 

        Facilitate communication among residents, responsible parties, SVWC providers, community providers, and the Interdisciplinary Team while maintaining resident choice, privacy, and confidentiality. 

        Conduct annual Independent Living resident assessments and assist residents in preparing for annual wellness visits with the SVWC Clinic. 

        Conduct a welcome orientation for new Independent Living Residents.

        Use available dashboards, electronic health records, insurance portals, and other approved tools to track provider recommendations, referrals, follow-up needs, and care coordination activities. 

        Provide education and guidance regarding community resources, insurance processes, advance care planning resources, and supportive services.

        Advocate for residents by helping them formulate questions, understand care options, communicate preferences, and address barriers to obtaining needed medical and social services. 

        Maintain timely documentation and follow-up contact after services are provided to support continuity, resident understanding, and completion of recommended next steps.

Administrative

        Assist with the development of and promote the philosophy, objectives and standards of the Social Services Department.

        Identify departmental needs and develop plans according to needs.

        Develop and revise policies and procedures for the Social Services Department as necessary.

        Assist with development and periodic updates of job descriptions for the Social Services Department.

        Assist with planning, monitoring, and controlling the budget for the Social Services Department.

        Serve and participate on committees affecting the overall operation of the community as needed.

        Participate in and complete documentation for Care Plans, Minimum Data Sets, and Individual Service Plans.

        Promote positive language and culture change understanding for persons living with dementia. 

Ability to make administrative/procedural decisions and judgments.
Ability to lead and train staff and/or students as related to the Social Service department.
Resident Care

                    Conduct psychosocial pre-assessments for outside admissions and recommend appropriate level of care.

                    Meet with resident and/or responsible party as needed to address and assist with psychosocial concerns.

                    Act as resident advocate, helping resident, responsible party, and staff understand the social and emotional factors underlying residents or families’ mood and/or behavior.

                    Prepare for and participate in discharge plans as necessary.

                    Provides and/or arranges for outside professional interventions as appropriate for the resident; follow up to determine that appropriate documentation of the service has been requested. 

                    Visit residents outside of the facility when needed.

                    Explore and utilize community resources as appropriate.

                    Works in collaboration with the Interdisciplinary Team to identify resident care needs.

                    Facilitates access to necessary medical and social services.

                    Conducts annual Independent Living Residents’ assessments and assists in preparation for annual wellness visits with SVWC Clinic Providers.

                    Ensures continuity of care by making follow-up contact after services are provided.

                    Remains flexible to cover psychosocial needs of residents.

                    Crosstrain with other department Social Workers to fill community needs as necessary.

                    Perform other duties and responsibilities as assigned.

Supervisory Responsibilities

        The community’s Social Workers will report directly to this position.

        This position typically supervises a team of up to 2 employees.

PHYSICAL AND ENVIRONMENTAL REQUIREMENTS:

Physical Requirements

        Ability to push, pull, and maneuver equipment, carts, stretchers, and similar items. 

        Ability to lift and carry up to 50 pounds occasionally and perform repetitive lifting of up to 10 pounds. 

        Frequent standing, walking, bending, reaching, kneeling, squatting, and use of hands for fine motor tasks.

        Sufficient mobility and manual dexterity to safely perform assigned duties.

        Must be able to use, operate and interpret information form equipment in work area.

Working Conditions

        Must be able to work under pressure and adapt to changing priorities. 

        May be required to work overtime, rotating shifts, or on-call schedules. 

        May interact with verbally or physically combative residents. 

        Must properly utilize personal protective equipment (PPE) and adhere to OSHA and organizational safety standards.

        This position may involve exposure to blood, body fluids, tissues, and other potentially infectious materials, including HIV, AIDS, and Hepatitis B. Employees are required to follow Universal Precautions and all applicable safety protocols when performing duties that may involve contact with these materials.

Mental and Cognitive Requirements

        Ability to read, understand, and follow written and verbal instructions in English. 

        Strong problem-solving, decision-making, and communication skills. 

        Ability to perform basic mathematical calculations and maintain accurate records. 

        Ability to exercise sound judgment, maintain attention to detail, and accurately recall information.

AN EQUAL OPPORTUNITY EMPLOYER

Shenandoah Valley Westminster-Canterbury does not discriminate on the basis of race, color, national origin, ancestry, age, religion, military and veteran status, sex, gender, gender identity, gender expression, sexual orientation, genetic information, marital status, medical condition, pregnancy, or any other legally-protected characteristic; and it will comply with all applicable state discrimination laws. No person will be denied employment solely because of a disability, provided that the person can perform the essential functions of the position for which the person has applied, either with or without reasonable accommodation.

Disclaimer

Offers may be contingent upon successful completion of Background Check, Drug Screen, Physical Examination, and /or potential Motor Vehicle Record.

This job description identifies the general nature and level of work to be performed.  It is not to be considered an exhaustive list of responsibilities, duties, or skills required of an incumbent.

I have read the job description above and fully understand the requirements set forth therein.

Requirements

REQUIRED EDUCATION, EXPERIENCE, SKILLS, LICENSURE:

Master of Social Work degree required.
        Experience in health care navigation, case management, social work, or a related medical field preferred.

        Experience or knowledge of managed-care pre-authorization processes preferred.

        Highly motivated, energetic, and able to work both independently and under the direction of the Director of Supportive Services.  

        Multi-tasker with excellent communication skills.

        Case Management certificate and UAI certification or ability to obtain.

Strong interpersonal and communication skills and the ability to work effectively with a wide variety of individuals within the facility as well as people from the outside community.
Interviewing and social work evaluation skills.
Ability to maintain emotional stability to cope with human suffering, emergencies, and other stresses.
        Must be able to use, operate, and interpret information from various online platforms, insurance portals, and hospitals’ EHR.