Patient Navigator


Date Posted:
Job Code:
57 Willoughby St Lower Level
United States of America



Position Overview

The Patient Navigator will provide care coordination services to members with chronic health conditions. Patient Navigator will act as an intermediary between providers and members – serving in numerous roles such as educator, evaluator, service coordinator, community resource researcher and more. The Patient Navigator will assist in achieving fewer emergency room visits and hospitalizations, better coordination of services, and social service navigation.

• Provides case management services including but not limited to: weekly and monthly progress summaries, quarterly assessments, quarterly care planning, counseling, outreach, case conferences, advocacy, referrals (on-site & off-site) and discharge planning.

• Completes initial assessment and quarterly reassessments on all assigned clients in a timely manner in-order to develop individualized treatment goals for each client.

• Establishes treatment goals and objectives with clients as part of the interdisciplinary team.

• Ensure timely submission of clinical documentations to care organization for uninterrupted services.

• Facilitates harm reduction strategies support groups as needed.

• Assess client’s needs for services and cooperatively develop an integrated care plan and goals with the client, family, and other providers.

• Coordinate transitional care from inpatient service to other settings as per care plan.

• Work collaboratively with team members to provide outreach and engagement too hard to reach clients.

• Maintain documentation and update care plans at specific time intervals or as needed in Housing Works and Health Home electronic medical records system.

• Assists clients to navigate the health insurance system including the AIDS Drug Assistance Program (ADAP).

• Assist clients in navigation of internal and external medical systems

• Conduct field work to members’ homes and other provider settings as needed to fulfill plan of care

• Participate in regular case conferences

• Provide assistance through advocacy and psycho-education to client and family for entitlements and other community services

• Understands and is sensitive to chronic medical conditions, including HIV, mental health and substance use, diabetes, asthma, hypertension, heart disease and hepatitis diseases

• Consistently exhibit Housing Works core values of team work, advocacy and customer service

• Performs other duties as requested

Minimum Requirements


Educational Requirements
• Bachelors’ Degree in social work or related field with at least two years of experience in a related social service field

• Minimum of 2 years of experience of care management

• Experience working with the adult population

• Ability to travel to member’s residence

• Knowledge of community health and social service agencies, public benefits and additional community resources

• Ability to make data entries into programs database such as AIRS, e-Share, EiCare

• Good group facilitation skills and overdose prevention training experience

• Skilled with health insurance navigation and documentation

. • Good verbal, written, communication and interpersonal skills.

• Use of computer software --Microsoft Office Suite including Word and Outlook calendaring, and Excel.

• Bilingual in Spanish/English helpful.

Housing Works provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements. Housing Works complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. Housing Works also does not request prior salary information during the hiring process. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. 
This position is included in a bargaining unit of Housing Works’ New York City employees represented by a labor union known as the Retail Wholesale and Department Store Union (“RWDSU”).  Accordingly, the RWDSU has the exclusive right to bargain over the terms and conditions of employment related to this position and this position may become covered by the terms of a collective bargaining agreement (a “CBA”) between Housing Works and the RWDSU.