Job Summary: Patient Navigators Community Health Workers (CHWs) are non-clinically licensed health care staff members who are frontline public health workers deployed in clinical and community care settings to improve the social health of Kaiser Permanente members in the communities we serve. Navigators CHWs act as the quarterback of the care plan for members who have unmet social, medical and behavioral needs. They work with patients, families/ caregivers, medical providers and community partners to coordinate care and services across the continuum. Navigators CHWs are highly trained communicators and subject matter experts, skilled in Motivational Interviewing and responsible for ongoing community and KP resource knowledge. Through building strong relationships and trust with members and their family/caregivers they can activate clinical care plans, identify patient centered goals and connect members to needed community resources to improve health outcomes and reduce total cost of care. The goal of the patient navigators CHWs is to help our members with real life issues that create barriers to their total health goals. Essential Responsibilities: • Help patients with social issues like houselessness, substance abuse and hunger • Assist patients with organization, making follow-up appointments, and filling prescriptions • Help patients fill out applications for benefits public assistance program examples are health insurance and food stamps • Meet patients in a community, clinic, or hospital and conduct a needs assessment, including helping patients to set health goals • Comfortable making follow-up calls and home/community visits to patients • Communicates all care and coordination activity, risks and care plans using standard documentation, information technology and care coordination tools in the electronic medical record. • Coordinates care with the right licensed professional, medical provider or community resource at the right time to ensure patient safety. • Be the system coordinator and point of contact for patients and families. May assume advocate role on the patients behalf to ensure approval of the necessary services or accessibility of needed resource(s) for the member in a timely fashion. • Create collaborative relationships with staff across departments within KP and externally to promote collaboration and multi-system coordination. • Increases access to health and heath care services through innovative health models, virtual care strategies and collaborative community partnerships. • Applies motivational interviewing and patient centered approaches to address concerns around cost, coverage and care to improve the care experience and motivate patients to meet their health goals • Ability to work independently with accountability and exercise sound judgment, discretion, and professionalism at all times • Good organizational and time-management skills • Available to work occasional evenings and weekends • Other duties as assigned • Ability to travel up to 80% of the time and independently meet with patients in the clinic, home, or community-based setting. • Participate in on-site events, clinics, and outreach initiatives as assigned