Job Description

Job Function Summary:

Involves providing non-clinical support, guidance and assistance for patients and families as they navigate through complex healthcare environments. Primary goals are to increase patient satisfaction, and to optimize care and outcomes. Acts as a communication liaison to understand the patient's non-clinical individual needs, desires, and concerns. Guides the patient and family to a broad range of services, amenities, and information to promote healing and ensure satisfaction with the patient care experience.

Generic Scope

Experienced professional who knows how to apply theory and put it into practice with in-depth understanding of the professional field; independently performs the full range of responsibilities within the function; possesses broad job knowledge; analyzes problems / issues of diverse scope and determines solutions.

Custom Scope

The HealthCareNavigator (HCN) is part of the Sickle Cell Center of Excellence (SCCoE) in collaboration with the Office of Population Health and willserveasa key resourceandliaisonfor patients with sickle cell diseaseandtheirfamilies supporting navigation across all aspects of the healthcare system. This role utilizes knowledge of clinic workflows, population health programs, and system resources to resolve patient barriers, enhance the care experience, and promote patient satisfaction.

The Health Care Navigator collaborates closely with department leadership, licensed clinical staff, the Sickle Cell Center of Excellence (SCCoE) team, and care teams to support patient-centered care, achieve quality outcomes, and contribute to a culture focused on equitable and efficient care delivery. The SCCoE is a lifespan program, this role will work with patients of all ages but with a special focus on adolescent and young adults (AYA).The Health Care Navigator maintains a comprehensive understanding of the services provided by the UCSF Office of Population Health (OPH), including the Population Health Outreach Team, Care Management, and Health Coaching programs. Core responsibilities include supporting quality improvement initiatives through the tracking and reporting of patient outcomes; delivering services aligned with provider care plans and the direction of licensed clinical staff; providing health coaching and Motivational Interviewing; conducting targeted patient outreach and care coordination to support care gap closure and patient engagement; and coordinating care for patients with sickle cell disease through collaboration with local and state initiatives, the Sickle Cell Center of Excellence (SCCoE) Community Advisory Board (CAB), and community-based organizations (CBOs) to connect patients with appropriate resources and services.

This position reports to the Manager, Care Navigation and accountability to the SCCoE leadership team for duties that pertain to the grant.

This position is an on-site role requiring a five-day-per-week presence unless otherwise indicated in the Annual Telework Agreement. The incumbent must have the flexibility to work across UCSF Health locations throughout East and West Bay locations.This position is expected to meet patients at locations such as their home, doctors’ office, other health care settings, or community settings to meet patient care needs.

The incumbent should also be able to provide a safe, secure, and private home office environment for conducting patient outreach, care coordination activities, virtual patient encounters, and other UCSF business functions if they are granted working remotely.

%

of time

Essential Function (Yes/No)

Key Responsibilities

(To be completed by Supervisor)

30

Core Responsibilities

• Patient Outreach & Engagement

• Care Coordination & Navigation

• Health Education & Self-Management Support

• Resource Connection & Barrier Resolution

• Documentation & Information Management

• Collaboration & Team-Based Care

• Quality & Professional Practice

25

Care Gap Closure/Care Coordination

• Creates rapport with patients with sickle cell disease primarily through telephonic outreach, while also providing in-person support when needed.
• Conducts outreach to assess care needs, schedule appointments, support care gap closure, and serve as a point of contact for patients requiring follow-up and care coordination.
• Supports closure of preventive and disease-specific care gaps and facilitates timely access to specialty and primary care services.
• Provides education regarding sickle cell disease, preventive care, treatment adherence, and available support services.

• Collaborates with providers, care teams, and community partners to improve patient engagement and health outcomes

15

Longitudinal Care Management

• Provides ongoing care management, health coaching, and self-management support for patients with sickle cell disease.
• Utilizes Motivational Interviewing techniques to promote behavior change and support achievement of individualized health goals.
• Reinforces provider-directed care plans, treatment recommendations, and disease management strategies.
• Monitors patient progress identifies barriers to care and facilitates problem-solving.

• Provides education related to sickle cell disease, treatment options, medications, pain management strategies, and self-management practices.

15

Care Coordination & Patient Navigation

• Coordinates care across providers, clinics, departments, hospitals, and community organizations to support continuity of care for patients with sickle cell disease.
• Assist patients with appointment scheduling, reminders, transportation, medication access, referrals, and linkage to internal and external resources.
• Coordinates transitions of care between inpatient, outpatient, emergency department, and specialty care settings.
• Serves as a liaison between patients, caregivers, providers, care teams, community-based organizations (CBOs), and community partners.
• Collaborates with local and state initiatives, the Sickle Cell Center of Excellence (SCCoE) Community Advisory Board (CAB), and community-based organizations to connect patients with appropriate resources, services, events, and support programs.

• Triages patient questions and facilitates resolution of administrative, financial, and clinical concerns.

10

Quality Improvement

• Documents patient interactions, outreach activities, and interventions in the electronic health record and outreach tracking systems.
• Maintains registries, reporting tools, and data collection processes to support quality metrics and program evaluation.
• Supports quality improvement initiatives, workflow development, and implementation of best practices for sickle cell disease care.
• Maintains current knowledge and participates in ongoing education related to sickle cell disease, emerging research, treatment advancements, and available local and state resources through attendance at conferences, trainings, and meetings.

• Serves as a subject matter expert for assigned sickle cell workflows, resources, and community partnerships. Education related to sickle cell disease, emerging research, treatment advancements, and available local and state resources through attendance at conferences, training, and meetings.

Serves as a subject matter expert for assigned sickle cell workflows, resources, and community partnerships

5

Other duties as assigned

• Perform additional responsibilities as assigned to support departmental and organizational goals.

100%

Required Qualifications

• Bachelor's degree in related area and / or equivalent experience / training

• Strong knowledge of Patient Rights & Responsibilities, Joint Commission standards, and Centers for Medicare / Medicaid regulations. Knowledge of Medical Terminology. Strong knowledge of data collection, compilation, and analytical techniques.

• Strong skills to comprehend and assess patient's grievances to quickly locate appropriate resources for assistance. In-depth knowledge of the organization and how to get issues resolved.

• Strong interpersonal and customer service skills. Ability to communicate and resolve issues effectively with a diverse population of patients, staff and physicians.

• Excellent analytical and problem-solving skills. Ability to develop solutions and recommend changes and follow through with implementation.

• Excellent written and verbal communication skills.

• Proficiency with Windows-based software including Microsoft word, Excel, Outlook. Knowledge of computer systems and software used in functional area.