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Company: The Institute for Family Health
Location: Bronx
Posted on: March 16, 2023

Job Description:

Job Details

Job Location
Urban Horizons - Bronx, NY

Remote Type
Optional Work from Home

Position Type
Full Time

Education Level
High School

Salary Range
$20.00 - $21.77 Hourly

Travel Percentage

Job Shift

Job Category
Health Care



The COMPASS Care Navigator is responsible for managing a caseload of patients living with HIV that are enrolled in the Care Coordination Program. The Care Navigator works as a part of a diverse, multi-disciplinary team, playing a vital and active role supporting the HIV health of their patients. The position works with their patients to address barriers to HIV treatment, viral suppression, or engagement in care as well as supporting patients to become physically and mentally health while living with HIV. The role is a mix of field-based and in-clinic types work, as well as community outreach efforts to connect patients to healthcare.

The mission of the COMPASS Programs is to provide individualized, patient-centered, comprehensive services, rooted in harm reduction with an anti-stigma, anti-racism, social justice lens. The COMPASS Care Navigator is an active participant in reaching this mission, and moving COMPASS programs to embody this mission.

COMPASS Programs are committed to hiring candidates that are reflective of the many diverse identities of our patients. Candidates that are from diverse identities and communities are strongly encouraged to apply.


  • Assists with the screening of all patients receiving HIV primary care at Institute sites for eligibility in the Care Coordination Program
  • Meets with enrolled and not-yet enrolled patients when they present for medical care or seen in the community, to engage in services and screen for needs
  • Carry out field and clinic based outreach, to re-engage patients to care
  • Sees, supports, and outreaches patients according to program guidelines, to ensure services are delivered with timeliness and quality
  • Responsible for independently monitoring their caseload to: track upcoming appointments, make appointment reminder and missed appointment outreach calls, make collateral and referral follow-up calls, engage in health education, and address viral suppression
  • Assists with the completing of program intakes, reassessments, care plans, and self-management assessments, when needed
  • Engages patients in individual sessions of health education, adherence counseling, harm reduction, barriers to viral load suppression and care through home, field and clinic based visits
  • Regularly assesses concrete needs, and supports patients via case management and care coordination efforts
  • Provides accompaniments for patients to attend healthcare and social service appointments
  • Regularly screens patients for mental health and substance use needs, assesses readiness for change and referrals, and refers for relevant resources
  • Provides occasional crisis intervention with the help of managers, as needed
  • Works closely with medical providers, nursing staff and others (internally and externally) to coordinate care for patients , through formal and informal case conferences, huddles, warm hand-offs, joint visits, referral/collateral contacts
  • Conducts creative outreach, using various strategies, to re-engage patients previously out of care several months
  • Completes timely and thorough documentation in Epic of all patient contacts. Qualifications

    • High School diploma or equivalent required
    • Bachelor's degree in social work or in related field preferred
    • Experience working with marginalized and underserved communities preferred
    • Experience working in HIV care, medical or social service preferred
    • General knowledge of HIV prevention and treatment
    • General knowledge of the impact substance use, mental health, and stigma have on health outcomes and engagement in services
    • Demonstrated organizational, interpersonal, oral and written communication skills and the ability to handle multiple assignments at any time
    • Familiarity with concepts of the stages of change, principles of harm reduction, and elements of motivational interviewing
    • Ability to engage with patients from many diverse communities, using an anti-racist, person-centered, and judgement free lens

Keywords: The Institute for Family Health, New Rochelle , CARE NAVIGATOR - COMPASS, Other , Bronx, New York

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