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PHO Navigator

Cape Cod Healthcare

Hyannis, MA
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Cape Cod Healthcare
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Job Details

Cape Cod Healthcare

Department: HCI Phys Health Org - PHO
Schedule: Full-time 40 Hours per week
Shift: Day/Evening Shift
Hours: 8a-4p Monday-Friday, occ. w/e, occ. holiday
Job Details:


Under the general supervision of the PHO Case Manager, Supervisor and/or Director of Clinical Operations, the PHO Navigator will assume primary responsibility for the PHO's ongoing relationship with PHO covered lives under risk ("PHO  Members" or "Member") who are appropriate for case management.  The PHO Navigator is part of the Helping Hands team at the PHO.  Generally, the PHO Navigator will assess PHO Member need for medical, behavioral, substance use disorder, social determinant or other care / support services whether furnished by a PHO provider or a community-based resource such as a community agency; and, PHO Navigator will work to ensure PHO Members gains needed access to same.



1.     Meets with PHO Members to assess need for PHO case management services.

2.     Reviews Member's history using a variety of health risk assessment tools and in cooperation with community resources, develop a care plan.

3.     Establishes contact, enrolls in case management and builds ongoing effective relationships with Members.

4.     Facilitates Member navigation and access to needed services as part of an integrated, overall "wrap-around" care coordination including PHO's Helping Hands program.

5.     Facilitates and coordinates follow-up care with referring services including but not limited to, behavioral, therapy, housing, legal, transportation and other social determinants of health needs

6.     Provides culturally appropriate health education, information and outreach in community-based settings, such as home, schools, clinics, shelters, local businesses and community centers.

7.     Coordinates referrals to community substance use and/or mental health services as necessary.

8.     Builds relationships with community partner agencies, groups and organizations to strengthen network of resources available.

9.     Works collaboratively with members of the PHO's multi-disciplinary team and communicates effectively with departmental staff, office practices, physicians, Members and Member's care giver.

10.   Performs other work related duties as reasonably requested/directed. 



  • Bachelor's level social worker or related healthcare field or minimum one year experience in navigating patient need for medical, behavioral, substance use disorder, social determinant or other care/support needs
  • Experience in outpatient/community outreach
  • Ability to develop effective working relationships with Members
  • Serves as liaison between communities and health care agencies
  • Ability to communicate clearly and effectively in person, in writing or by phone
  • Familiarity with Cape Cod community resources and ability to access same
  • Familiarity and ability to work with diversity of cultural/socio-economic background
  • General knowledge of cultural backgrounds of patients to be served
  • Proficiency with computers and most commonly used Microsof

HR Use Only:

Zip Code: 02601
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