Patient Navigator; MHL Administrative and Community Office

Benefits

• PSLF- qualied employee
• Dental insurance
• Health insurance
• Opportunity for advancement
• Paid time off
• Parental leave
• Training & development
• Vision insurance
• Wellness resources

The Patient Navigator provides support, advocacy, and care coordination for individuals accessing mental health and supportive counseling services, with a specialized focus on People Living with HIV/AIDS (PLWHA). The Patient Navigator works closely with clinical and support staff to ensure clients receive comprehensive care, including mental health services, substance use support, housing assistance, and linkage to medical care and social service providers.

This role is critical in reducing barriers to care, improving engagement in services, and supporting clients in navigating complex healthcare and social service systems. The Patient Navigator provides culturally responsive, trauma-informed, and person-centered support to empower clients and enhance their overall well‑being.

The major responsibilities of this position include, but are not limited to:

• Serve as a primary point of contact for clients seeking mental health and supportive counseling services.
• Conduct client intakes, needs assessments, and care plans.
• Develop and maintain up-to-date risk assessment, linkage to care, treatment adherence assessments.
• Provide education, emotional support, and advocacy to individuals with HIV/AIDS navigating behavioral health care.
• Support clients in adhering to their mental health treatment plans and medical care.
• Schedule clients for office/home visits to conduct service plan updates, wellness checks, and/or reassessments.
• Provide ongoing support to encourage retention of services.
• Conduct re‑engagement activities via a series of phone calls, written correspondence, and/or in person visits to the client’s place of residence.
• Create a safe and professional and welcoming environment for clients of the priority population.
• Provides home, hospital, or community site visits and escorts patients to medical and non‑medical appointments, as indicated and as approved by the Clinic Supervisor and/or Clinic Director.

• Reviews referrals and assesses patients for individual services.
• Identify supportive services that will benefit the health and well‑being of the client and effectively refer them to necessary services.
• Assist clients in accessing primary care, substance use treatment, housing support, and other community resources.
• Develop strong partnerships with healthcare providers, service providers, and community‑based organizations.
• Support appointments adherence through accompaniment, referring, scheduling and re‑scheduling assistance.
• Develops, implements, and reassesses care plans to address barriers to expected health outcomes and self‑management and to address patient needs and assure continuity of care.
• Collaborate with and consult with other team members in identifying services gaps and needs.
• Attend community events and health fairs to build community partnerships.
• Facilitate warm hand‑offs and follow‑up to ensure continuity of care.

• Provide HIV/AIDS education and promote engagement in treatment and adherence strategies.
• Educate clients on mental health wellness, harm reduction, and self‑care techniques.
• Facilitate individual counseling, support groups and workshops on behavioral health and wellness topics.
• Educate clients on life skills such as budgeting, food shopping, health living, physical and mental health well‑being.

• Identify and address barriers to care such as stigma, homelessness, food insecurity, or lack of insurance.
• Assist clients in navigating Medicaid, ADAP, HOPWA, Other Ryan White programs, and other assistance programs.
• Advocate for clients in healthcare settings and with social service agencies.

• Maintain accurate and timely records in Electronic Health Records (EHR) and other required databases in accordance with agency protocols and standards.
• Document each encounter with each client via accurate progress notes.
• Ensure…