Job Details

On-Call Patient Navigator

Central City Concern is an innovative nonprofit agency providing comprehensive services to single adults and families in the Portland metro area who are impacted by homelessness, poverty and addictions. We hire people that are skilled and passionate to meet our mission to end homelessness through outcome-based strategies which support personal and community transformation.

The Recuperative Care Program (RCP) is an innovative service that provides immediate access to emergency housing, primary care, and intensive case management support for individuals who have medical support needs while experiencing homelessness. The service partners with Portland area hospitals and clinics, in concert with CCC's patient-centered medical home, to help clients/patients receive the right level of care and support for their medical and social needs.

The OC Patient Navigator fills in as a critical member of a multi-disciplinary team providing intensive case management for patients enrolled in the program, working to support patients through the experience of their RCP stay. This support includes welcoming and orienting new participants, engaging with them on a daily basis, and coordinating resource support needs as well as linkage to medical services to manage their acute needs and ongoing care. The OC Patient Navigator is skilled in crisis management and provides timely referral to appropriate substance abuse, physical health, and mental health treatment, support in accessing benefits and entitlements, and support in identifying appropriate and affordable housing as part of a comprehensive approach to ending homelessness and achieving self-sufficiency.

The OC Patient Navigator works to provide coverage for the primary point person for managing a caseload of program participants, working to meet the case specific medical, behavioral health, and housing needs of the individuals they serve. The population served includes many people who have been chronically experiencing homelessness, often with co-occurring substance use and mental health support needs in addition to the acute and/or chronic medical conditions for which they are receiving support.

Location: Evergreen Crossing/Recuperative Care Building (8225 NE Wasco St. Portland, OR 97220)

Schedule: Shifts are available Sunday through Saturday. SWING: 4:00pm - 12:30pm and NOC: 12:00am - 8:30am.

On-call employees are asked to work at least 1 shift per 6 month period to remain active.

Minimum Qualifications

• Education and experience sufficient to succeed, carry out responsibilities, and demonstrate the skills and abilities described above with at least one year of experience working in a pre-hospital or post-hospital setting.
• Must have current Healthcare Provider CPR/First Aid certification prior to start date.
• If driving, must possess a current driver's license, pass a DMV background check and be designated an "acceptable" driver as outlined in Central City Concern's Fleet Safety Policy. Must pass an initial drivers training within 60 days of being an approved driver and continued recertification training.
• Those with relevant lived experience are encouraged to apply.
• Bachelor's degree in a healthcare-related field preferred.
• Must have an understanding of the causes of homelessness, the medical and psychosocial sequelae of homelessness, and the systems and processes used to help clients secure and maintain stable housing.
• Must have a high tolerance for ambiguity and change.
• Must have ability to relate to patients who are substance-affected with acute mental health issues and poor hygiene.
• Must have a working knowledge of medical terminology.
• Must be able to be trained in the use of Electronic Health Records system.
• Must have non-violent de-escalation training, or complete within 90 days of hire.
• Will be required to carry an agency cell phone for work use. Cell phone will be provided by Central City Concern.
• Ability to adhere to Central City Concern's drug-free workplace which encourages a safe, healthy and productive work environment and strictly complies with the Drug-Free Work Place Act of 1988. An employee shall not, in the workplace, unlawfully manufacture, distribute, dispense, possess or use a controlled substance or alcohol.
• Must have excellent reading and comprehension skills.
• Must be available to work weekends and/or holidays and on-call hours when necessary for the program.
• Must be able to work efficiently in a very fast paced environment.
• Must generally have the ability to walk, bend, stoop, kneel, squat, twist, reach, pull and lift up to 50 pounds, and climb stairs with reasonable or no accommodation.
• Must pass a pre-employment drug screen, TB test, and background check. This includes clearance by the DHS Background Check Unit and the ability obtain ID-Badge at Partner Hospitals.
• Must adhere to agency's non-discrimination policies.
• Ability to effectively interact with co-workers and patients with diverse ethnic backgrounds, religious views, political affiliation, cultural backgrounds, life-styles and sexual orientations and treat individuals with respect and dignity.

Essential Duties and Responsibilities

• Fill in for regular Recuperative Care staff as needed based on program capacity, staffing, and task needs.
• Work under the medical direction of the Recuperative Care Program to coordinate acute and ongoing medical care for current Recuperative Care patients in conjunction with Recuperative Care staff.
• Serve as primary point of contact for internal and external care coordination and resource linkage for patients on caseload.
• Assist patients with obtaining prescribed medications and supporting patient in plans to self-administer medications as prescribed.
• Perform welfare checks and charting on patients enrolled in the Recuperative Care Program.
• Review hospital charts and internal medical records and obtain releases from patients to gather collateral information. Create patient charts and update electronic medical records in a timely manner with patient interactions, appointments and encounters.
• Actively participate in inter-disciplinary case collaboration, including regular caseload reviews with RN Complex Care Manager.
• Within interdisciplinary collaboration, develop, implement and maintain a case plan to as needed for patients upon admission to the program.
• Support patients in coordinating with their primary care providers, specialty medical providers, and other health service providers when health concerns are raised or observed.
• Identify, create, and implement behavioral interventions when appropriate, in conjunction with interdisciplinary team and Integrative Care Manager.
• Coordinate medical, behavioral health, services available to patients as care plan develops and as directed through medical support structure.
• Effectively de-escalate heightened situations with patients experiencing trauma, exacerbated mental health symptoms, and behavioral complexity.
• Work to identify housing and/or placement options relevant for patients and work to support patients in overcoming barriers to accessing housing or placement. Collaborate with housing specialists and/or other resources as available to support patients in achieving housing goals.
• Follow Policies and Procedures of Recuperative Care.
• Exercise Trauma Informed Care and Harm Reduction principles in providing care for RCP participants.
• Respond to emergency medical situations as needed, complete pre-hospital care reports and incident reports when necessary.
• Provide and/or arrange for transportation for patients to and from program related appointments, interviews, and hospitals/clinics.
• Screen patient referrals via phone and/or at partner hospitals upon identification of patients referred for Recuperative Care.
• Work with other Recuperative Care and Central City Concern staff to support patients in coordinating their health care with their primary care provider and/or specialty healthcare services.
• Attend clinical meetings as structured and provide current information to team regarding caseload.
• Participate in case reviews with Recuperative Care team (including RN Complex Care Manager, Case Managers, Logistics Specialist, Housing Specialist, Program Assistant and clinical, logistics and operations volunteers) to ensure quality care for patients in Recuperative Care, including helping to identify and address psychological, social and medical needs.
• Participate in compliance, quality assurance and quality improvement activities as directed.
• Transport clients when needed (Only if approved CCC driver).
• Adhere to all state and federal privacy regulations, including HIPAA and 42 CFR Part 2, and to CCC policies and agreements regarding confidentiality, privacy, and security. Support compliance with all privacy and security requirements pursuant to community partners' and outside providers' patient confidentiality agreements, including privacy and security requirements for EMR access. This includes immediately reporting any breach of protected health information or personal identification information of any person receiving CCC services by CCC or an outside provider to the CCC Compliance Department, as well as to your supervisor or their designee.
• Attend all mandatory CCC trainings in a timely manner.
• Perform other duties as assigned.

Skills & Abilities