Health Navigator-Elders and Disabilities-Closes 01/03/2025 - Siletz Tribal Gaming Commission : Job Details

Opening Date: December 20, 2024Closing Date: January 3, 2025Job Title: Health Navigator-Elders and DisabilitiesSalary/Wage: $28.41Tribal Level TL118Location: Siletz, OregonClassification: Full time, Non-exemptJob Posting Number: 2931719INTRODUCTION:The function of the Health Navigator is to assist vulnerable patients in meeting their health needs and promoting wellness. Health Navigates will work with all patients requiring extra services to benefit their health, with special attention to patients living with disabilities and elderly patients no longer able to live independently without interventions. Services will include attending appointments with patients, providing the most appropriate, fully vetted resources to patients and staff throughout the clinic regarding tribal and community programs that support individual health and wellness needs. DUTIES:

• Develop a comprehensive, collaborative care plan, based on a provider treatment plan, evidence-based chronic care guidelines, and patient/family goals for patients, recent discharges, and those in care transition to promote adherence to physician/provider recommendations and instructions.
• Elders or people with disabilities within the Tribe's service area by referral including:
• 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.
• Address medication adherence.
• Follow-up with assigned patients on all labs, tests, and consults to ensure work is done.
• Provide education to patients regarding health conditions.
• Collaborate in goal planning and care management.
• Communicate changes in patient's status appropriately with the care team.
• Perform an after-visit summary review with navigator patients when appropriate.
• Identify barriers when treatment goals are not met, treatment plan is not being followed, or important appointments are missed.
• Collaborate in developing patient treatment goals.
• Identify patients who are overdue for visits, labs, and referrals, contact patients, and arrange for follow-up services.
• Assist the patient in improved healthcare access and promote patient knowledge of health and behavior change.
• Facilitate the initiation of diagnostic services, treatment planning, and therapeutic treatment while the patient is enrolled in the program case management.
• Create and update patient care plans in the electronic health record.
• Liaison with insurance companies for patients with chronic illness.
• Consult with the medical staff, nursing staff, and ancillary department staff to eliminate barriers to the efficient delivery of care. Identify service delivery problems and potential for effective patient management intervention.
• Provides consultation to tribal health programs, including, but not limited to: Housing, Indian Child Welfare, Education, Self-Sufficiency, and Elders Programs.
• Participate in regular team meetings, huddles, staff meetings, and quality improvement projects to improve patient care.
• Provides quarterly and annual program reports as required.
• Utilize appropriate protocols and standing orders in delivering patient care.
• Serve as a clinical resource and community referral resource within the practice.
• Accepts and performs other duties as assigned.

RequirementsREQUIREMENTS:High School diploma or GED, and four (4) years experience in direct patient care in a clinical health care setting - OR - an equivalent combination of education and/or experience. The candidate must possess knowledge of the Siletz tribal member community and unique health concerns affecting Native Americans.Knowledge of:

• Services to patients with disabilities and elderly patients related to health and social challenges such as chronic illness, mental illness, grief, and transition, substance abuse, and senior abuse.
• The role of DHS Case Managers concerning Medicaid eligibility for access to Medicaid or Older Americans Act services, whichever is most appropriate for tribal elders or people with disabilities.
• Basic preventive health practices in the areas of nutrition, tobacco, alcohol, drug use, physical activity, communicable disease, and routine health screenings.
• The assessment process, and the tools used to conduct the assessments.
• Ability to assist individuals, families, and groups of various ages and educational levels using culturally appropriate methods.
• Support Group organization and facilitation.
• Tribal services, community/state/national resources for health, welfare, and social needs.
• Healthcare systems and payment mechanisms utilized by Siletz tribal members, including Purchased/Referred Care, Oregon Health Plan, and IHS medical facilities.
• Local, private, and county healthcare service systems and individual medical providers.
• Resources available to support people living with disabilities and tribal community elders.

Ability to:

• Conduct pre-screening assessments of tribal elders or people with disabilities for the most appropriate referrals to DHS for APD services as approved Consumers. The Tribal Navigator will also act as a resource for referral in addition to DHS-related referrals, providing information to tribal elders or people with disabilities about other state agencies to be considered as a resource for tribal elders or people with disabilities.
• Build and maintain client rapport and trust through a nonjudgmental attitude, advocacy, timely follow-up to client requests, and unconditional positive regard/respect (harm reduction model).
• Maintain personal and professional boundaries with clientele.
• Act as a liaison between tribal community elders or people with disabilities providing them assistance by navigating them through the various application processes and DHS systems and other state agency programs and systems to optimize access and opportunities for eligibility for Medicaid Long Term Services and Supports and Older American Act services available.
• Exercise good judgment in situations significantly impacting client and/or own safety and well-being.
• Effectively develop working relationships with all tribal program staff.
• Collaborate with the Oregon Home Care Commission to seek opportunities for potential home care workers, as identified by tribal elders or people with disabilities. Identify training needs for Home Care Workers and schedule training sessions
• Communicate effectively both verbally and in writing.
• Utilize computer applications used in providing patient care and maintaining records.
• Travel locally and longer distances in accordance with tribal transportation policy.

Other:

• CPR card required or ability to acquire within 30 days of hire and maintain without lapse.
• Must possess a valid driver's license, and insurance and be eligible to drive a GSA vehicle.

Salary Description $28.41