Clinical Health Navigator - Licensed Independent Social Worker

Title: Clinical Health Navigator - LISW

Division: Healthcare

Status: Exempt

Reports to: Director

Revision date: August 2025

Supervises: n/a

PURPOSE

According to prescribed policies and procedures of the organization including all applicable federal, state and accreditation regulations and under the general supervision of the Director , the incumbent will be responsible for comprehensive care management focusing on facilitating care transitions, addressing social determinates of health, ensuring patients receive appropriate services and driving current care initiatives.

ESSENTIAL FUNCTIONS

• Conduct assessments through various modalities including phone, in-person, and virtual interactions with patients.
• Coordinate care across diverse settings such as hospitals, skilled nursing facilities, and community-based services, including development of individualized care plans that consider social determinants of health (SDoH).
• Facilitate smooth transitions of care to help minimize unnecessary service utilization.
• Collaborate with interdisciplinary teams to ensure care plans reflect patient goals, making adjustments as needed.
• Monitor adherence to care plans and document activities to support quality metrics and administrative billing requirements.
• Initiate conversations about care goals, advance directives and healthcare proxies, assisting patient with documentation as appropriate.
• Educate patients and families on supportive care options, including palliative and hospice services, to align care with patient wishes.
• Identify and address social factors affecting health and service delivery, gathering and evaluating data to enhance access, efficiency, and satisfaction.
• Recognize and respond to behavioral health concerns such as emotional distress, substance use, and other psychosocial factors influencing health.
• Connect patients to behavioral health resources, housing, nutrition support, and other community-based services as needed.
• Assist patients in understanding and navigating insurance, benefits, and eligibility for services.
• Ensure compliance with HIPAA other privacy and confidentiality regulations.
• Serve as a liaison among healthcare professionals involved in the patient's care.
• Maintain accurate records and meet performance expectations established by the team.
• Foster collaborative relationships with internal teams to support coordinated care.
• Establish and maintain relationships with external agencies to serve as resources for patients and organizational staff.

EXPECTATIONS

• Demonstrates and maintains a positive, professional manner, manages time efficiently and effectively, provides leadership as a role model to promote a team approach, collaborates and participates in policy creation and appropriate problem-solving methods.

• Must adhere to all policies, procedures, terms and conditions set forth in the National Church Residences' Employee Information Guide (EIG), the Code of Conduct, as well as any facility handbook, including but not limited to, corporate compliance, drug free workplace, safe work practices, all federal, state, local regulations and laws.

• With respect to Resident Rights, ensures all care is provided with respect and dignity for the residents/clients, their families and the staff. Reports all complaints made by residents/clients and/or families to the appropriate supervisors, reports all allegations of abuse, misappropriation of funds/resident property and/or any other corporate compliance, drug free workplace, safe work practices, all federal, state and local regulations and laws.

• Completes all annual education requirements timely, including but not limited to Compliance, Privacy, Security and HIPAA training and exhibits behavior as set forth by the Code of Conduct in the performance of their duties.

• Performs other duties as assigned.

Education: Master's Degree in social work from a school of social work accredited by the Council on Social Work Education.

Experience: Preferred minimum of two (2) years in varied multi-disciplinary settings in the healthcare field with experience working with clients and family counseling; however, requires one year of social work experience in a healthcare setting.

Travel: Frequent

Mental: Must have good communication, comprehension, computer and interpersonal skills. Must have the ability to speak, read, write and understand English.

Licensure:Must have a current licensed independent social worker license in good standing.

Vision: Normal: Consistent with standard workflow.

With respect to said job description, estimate the daily time spent performing the following activities.

Rare (R) = 0 - 24%; Sometimes (S) = 25 - 49%; Frequent (F) = 50 - 74%; Continuous (C) = 75% plus.

R = Climbing R = Stooping Lifting/Carrying: S = 10 - 25 lbs

S = StandingR = Pushing S = 26 - 50 lbs

S = Sitting R = Pulling R = 51 - 75 lbs

F = Walking F = Driving R = 76 plus lbs

Consequences of Errors: Moderate monetary responsibility.

Supervision Received: General supervision: Employee generally operates by himself/herself checking with supervisor when in doubt.

Working Conditions: Due to visiting clients in home/facilities, exposure to some disagreeable conditions such as noise, odors, illness, infection and physical contact and disruptive clients.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, ancestry, military status, disability, genetic information and/or any other characteristics protected by applicable law.