Community Resource Navigator

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Job Description:

  • Conduct outreach to designated members through face‑to‑face visits, phone calls, and mail
  • Assist members in navigating health care and social service systems, including assisting with filling out applications, arranging transportation, scheduling appointments, and accompanying members
  • Communicate member needs related to prevention, wellness, medical care, behavioral health, care transitions, and Social Determinants of Health (SDoH) to the Interdisciplinary Care Team (ICT)
  • Complete initial and periodic needs assessments, including barriers, basic needs, strengths, and SDoH
  • Help develop and implement member-centered care plans by helping members understand instructions and tailoring communication
  • Assess readiness to change and help members modify daily routines to support health goals
  • Identify and follow up on referrals to community-based resources
  • Use health information technology to link members with services, resources, and the interdisciplinary care team
  • Document all member interactions, activities, and interventions in TruCare or designated systems

Requirements:

  • 2+ years of experience with community resources, health agencies, or social services (e.g., Area Agency on Aging, DME providers, Meals on Wheels)
  • 1 year of experience working with electronic documentation
  • Ability to travel up to 75%, within Southeastern/South Central Wisconsin
  • Community Health Worker training or certificate or willingness to complete within one (1) year
  • Bachelor's degree in social work or related field
  • Knowledge and ability to facilitate use of health care system (e.g. primary care and specialty linkages; appointment scheduling etc.)
  • Experience with health education, promotion and wellness, chronic disease prevention and management and knowledge of health condition-specific treatment or management
  • Bilingual skills

Benefits:

  • medical, dental and vision benefits
  • 401(k) retirement savings plan
  • time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
  • short-term and long-term disability
  • life insurance
  • many other opportunities
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