Patient Navigator

The JaxHATS Program is a primary care medical home that provides Health Care Transition (HCT) services to youth and young adults ages 13-23 with special health care needs as they emerge from pediatric to adult based health care system.  The mission of the program is to provide a continuum of comprehensive, accessible, equitable and quality health care for youth and young adult living with special health care needs in Northeast Florida.

The National Health Corps (NHC) Member would serve with our interdisciplinary team to provide HCT services in the outpatient clinic and inpatient setting. Families and youth transitioning from pediatric to adult based systems often need guidance to navigate complex micro, mezzo and macro systems such as public benefits, insurance, education, vocation, peer support needs and to develop self-management skills. This requires ongoing support to identify community resources, navigation of health and social care systems, and, follow up and assistance to ensure completion of non-medical referrals placed.

In addition, a NHC Member would assist in the ongoing implementation of outpatient and inpatient transition services. This would include providing patients and families with information about transition from pediatric to adult based care through a transition readiness questionnaire and survey tool, which has been successfully developed, utilized and vetted. The NHC member will serve as the primary point of contact when consultation or referral for some non-medical services, HCT plan, or peer counseling is requested and collaborate with our team to provide these services.  Some examples of services may include: virtual tours of the adult hospital for pediatric patients and families, educating patients and families on self-advocacy skills during inpatient stays, transition planning activities (insurance planning, education/vocation planning etc.), assisting patients and families in navigating health services and educating hospital staff and providers about the importance of HCT.

• Screening patients for health concerns and eligibility
• Completing and submitting patient applications for social services and medication assistance programs
• Following-up with patients to ensure documentation is completed
• Providing education on how to complete paperwork
• Providing brief health education to patients
• Coordinating with other programs to provide health classes
• Tracking, enrolling, and surveying patients for improvement
• Informal one-on-one training on client referrals
• Following-up with companies to verify application status
• Attending meetings and patient huddles,
• Preparing and reviewing intake checklists/consent forms
• Conducting phone outreach as assigned by leadership
• Assisting in care coordination and resource referrals
• Tracking referrals and closing the referral loop
• Evaluating referral charts and obtaining reports
• Conducting outreach to patients via phone/letters,
• Interacting with patients to complete quality reviews
• Utilizing survey tools to upload date from interviews
• Conducting extensive and continuous research on social services
• Creating social service resources guides and lists for clients
• Counseling clients on how to access social services and benefits
• Developing various programs on improving health literacy
• Developing assessment tools to track patient improvement
• Coordinating for resource distribution with other programs
• Scheduling and coordinating communication for outreach visits
• Assessing community data to locate areas that would benefit from community health screenings and referrals
• Registering patients as well as providing follow-up social service navigation
• Finding additional community resources and programs for patients

• Comfortable with diversity
• Basic knowledge of medical terminology
• Proficient computer and data entry skills (e.g., Microsoft Excel)
• Self-manager
• Good communication skills
• Outgoing
• Independent
• Open-minded
• Takes initiative
• Comfortable in fast-paced environment
• Organized; sound organizational skills
• Good customer service
• Good telephone skills
• Flexible
• Persistent

• Knowledge of AmeriCorps/National Health Corps member requirements
• Skill with Microsoft Office or other software for a variety of data processing operations involving a range of problem solving, record keeping, correspondence, and service tracking options
• Knowledge of the host site's program and comfortable with serving youth and young adults with special health care needs
• Being comfortable with counseling and having discussions with patients and their families about health care education and social care services.

Member uses initiative in carrying out recurring assignments following set procedures, independently.

The supervisor assigns service activities, advises on changes in procedures, and is available for assistance when required.

The supervisor assigns service activities in terms of project objectives and basic priorities and is available for consultation in resolving controversial issues.

Completed projects are reviewed very generally to determine that objectives have been met and are in compliance with policies and regulations.

The Member embraces being self-aware and comfortable with asking for assistance and consultation for completing projects.

Written and oral guides provide specific instructions for doing service.

Detailed guidelines exist, including regulations and directives, handbooks, precedents, industry standards and files of previous projects.

Guidelines are generally applicable, but the Member independently makes adaptations in dealing with problems and unusual situations.

Member has to develop, analyze, or evaluate information before the service position can progress.

The facts or conditions of the service position are clear cut, predictable, and apply directly to the assignment.

Member has to review services and develop a good understanding of the services, population and policies before the service position can progress.

• Special safety regulations or precautions that must be observed.

• Personal vehicle is not required, but recommended for accessibility to position location. Host site is accessible by public transportation.

• NHC member should adhere to University of Florida Health Jacksonville dress code policy

Member cannot serve in this position with a criminal record.