Community Health Navigator - Baltimore, MD

MedZed delivers value-based, technology-enabled social support to high-cost Medicaid members who have been unreachable through traditional outreach methods, disconnected from primary care, and utilizing emergency and hospital services as their primary source of care. We combine innovative technology with field-based outreach to engage members, reconnect them to healthcare services, address Health-Related Social Needs (HRSNs), and empower individuals to better manage their health and wellbeing.

• High school diploma or equivalent.
• Experience working with individuals in healthcare, community health, social services, care coordination, outreach, customer service, or a related field.
• Strong interpersonal and communication skills.
• Ability to establish rapport with individuals from diverse backgrounds.
• Strong organizational and time-management skills.
• Ability to work independently and manage a caseload with limited direct supervision.
• Comfortable conducting telephone outreach and in-person community/home visits.
• Reliable transportation and ability to travel throughout the assigned service area.
• Ability to use technology, electronic documentation systems, Microsoft Office or comparable tools.
• Ability to maintain confidentiality and comply with HIPAA requirements.

The program will focus on Medicaid members who are disengaged from primary care, have multiple chronic conditions, and have identified gaps in care. The program will provide ongoing community-based engagement to help members establish or reconnect with primary care, address identified care gaps and overcome barriers to accessing appropriate healthcare services.

The program will also support members with complex medical and social needs by addressing social determinants of health (SDOH), connecting members to appropriate community resources, and helping reduce barriers that may contribute to poor health outcomes and avoidable healthcare utilization.

The Community Health Navigator (CHN) is responsible for engaging, supporting, and navigating members through a short-term care coordination program designed to improve access to primary care, addressing social determinants of health (SDOH), and close identified care gaps.

The CHN works directly with members who may be unengaged with their primary care provider (PCP), have unmet healthcare needs, or require assistance navigating the healthcare system. The Navigator helps members establish or reconnect with a PCP, locate a new provider when needed, address barriers to care, and complete recommended preventive and chronic care services.

This is a highly member-facing, field-based position requiring a combination of telephone outreach, community-based engagement, and in-person member visits. The CHN is expected to independently manage an assigned caseload and work toward defined program goals during the member's approximately three-month engagement period.

CHN does not work as part of a clinical team and will report directly to the Manager. The Navigator is expected to exercise sound judgment, maintain consistent communication with members, document all activities accurately, and ensure members receive the appropriate support to achieve their identified goals.

This position requires regular community-based outreach and home visits. The CHN must be comfortable meeting members in their homes and community settings and conducting outreach in accordance with MedZed safety protocols.

Responsibilities may include:

• →Traveling throughout the assigned service area to conduct member visits.
• →Completing scheduled and unscheduled field outreach, including door knocks when appropriate.
• →Following MedZed's field safety and live-location requirements.
• →Maintaining reliable transportation and the ability to travel throughout the assigned territory.
• →Planning daily routes efficiently to maximize member engagement and productivity.
• →Exercising appropriate judgment regarding personal safety and escalating concerns when necessary.

• Conduct telephone and field-based outreach to assigned members to introduce the program, establish trust, and obtain consent for services.
• Utilize telephone calls, door-to-door outreach, and other approved engagement strategies to locate and engage members.
• Verify member identity and eligibility during outreach and document successful member location, engagement, and consent.
• Build trusting relationships with members while maintaining professional boundaries and confidentiality.
• Maintain consistent contact with members throughout the program to support engagement and completion of identified goals.
• Identify barriers that may prevent members from accessing healthcare or completing recommended services.
• Provide culturally responsive, member-centered support based on the individual's needs, preferences, and circumstances.

• Assist members who are not currently engaged with their PCP in establishing or re-establishing primary care.
• Support members in locating a new PCP when their assigned provider is no longer appropriate, unavailable, or does not meet their needs.
• Assist members with scheduling and preparing for PCP appointments.
• Follow up with members to confirm appointments and identify barriers that could prevent attendance.
• Encourage ongoing engagement with primary care beyond the immediate program period.

• Educate and encourage members to complete identified preventive and chronic care services.
• Support members in closing identified care gaps, which may include:
  • Breast cancer screening
  • Colorectal cancer screening
  • A1C monitoring/testing
  • Blood pressure monitoring
  • Other plan-identified preventive or chronic care needs
• Coordinate with members and healthcare providers, as appropriate, to facilitate completion and documentation of care gaps.
• Follow up with members after appointments or screenings to confirm completion and identify any remaining needs.
• Accurately document care gap outcomes and supporting information.

• Identify SDOH barriers affecting a member's ability to access or maintain healthcare.
• Assist members with navigating available community and healthcare resources.
• Connect members with appropriate resources related to needs such as transportation, food insecurity, housing, utilities, financial assistance, and other identified barriers.
• Follow up with members to determine whether referrals or resources were successfully accessed.
• Document SDOH needs, interventions, referrals, and outcomes.

• Independently manage an assigned member caseload throughout the approximately three-month program.
• Prioritize outreach and follow-up based on member needs, acuity, program requirements, and outstanding goals.
• Maintain consistent engagement with members during the period of consent.
• Identify members who have completed their goals and are appropriate for program graduation.
• Identify members who require additional support or follow-up and communicate concerns to the Regional Manager.
• Maintain an organized schedule that balances telephone outreach, field visits, member appointments, documentation, and administrative responsibilities.

• Document all member interactions, outreach attempts, outcomes, and interventions in Salesforce and other required systems.
• Ensure documentation is timely, accurate, complete, and aligned with program and client requirements.
• Maintain accurate records of member consent, PCP appointments, care gap status, SDOH interventions, and successful encounters.
• Utilize required technology and communication platforms, including Salesforce, RingCentral, Guardian, and other MedZed systems.
• Maintain appropriate member confidentiality and comply with HIPAA and all applicable privacy and security requirements.

The CHN is accountable for achieving program KPIs and maintaining consistent performance throughout the member's engagement period. Key performance indicators include:

• Successful member engagement and consent
• Successful member location
• Consistent engagement throughout the consented period
• PCP appointment scheduling and completion
• PCP connection/reconnection rates
• Care gap closure rates.
• SDOH identification and resolution/referral outcomes
• Successful member encounters
• Timely and accurate documentation
• Appropriate program graduation/discharge

The CHN is expected to understand program goals and independently manage daily activities to support both member outcomes and contractual performance expectations.

Although this position does not have an assigned clinical team, the CHN is expected to collaborate effectively with internal and external stakeholders.

This includes:

• Communicating regularly with the Manager regarding caseload needs, barriers, member concerns, and performance.
• Escalating complex member situations or issues outside the Navigator's scope.
• Communicating appropriately with healthcare providers, health plan representatives, community organizations, and other approved partners.
• Participating in team meetings, huddles, training, and performance discussions.
• Sharing trends and barriers identified through member engagement that may impact program performance or member outcomes.

The CHN serves as a trusted point of contact for members and helps reduce barriers between members and the healthcare system. The Navigator should advocate for members while maintaining appropriate professional boundaries and recognizing that the role is to navigate and support—not provide clinical care.

The CHN should:

• Meet members where they are and use a person-centered approach.
• Help members understand available healthcare and community resources.
• Encourage members to take an active role in their healthcare.
• Identify barriers early and work with members to develop practical solutions.
• Promote independence and self-management rather than creating long-term dependence on the program.

• Experience as a Community Health Worker, Community Health Navigator, Care Coordinator, Patient Navigator, Medical Assistant, CNA, LPN, or similar healthcare/community-based roles.
• Experience working with Medicaid or managed care populations.
• Experience addressing social determinants of health.
• Experience with healthcare outreach, member engagement, or care gap closure.
• Knowledge of the Maryland healthcare and community resource landscape.
• Bilingual or multilingual skills based on the needs of the assigned population.

• Member Engagement: Builds trust and maintains productive relationships with members.
• Communication: Communicates clearly and effectively with members, providers, internal leaders, and external partners.
• Accountability: Takes ownership of assigned members, goals, documentation, and performance expectations.
• Organization: Effectively manages competing priorities, field visits, outreach, follow-up, and documentation.
• Problem Solving: Identifies barriers and develop practical solutions with members.
• Adaptability: Adjusts outreach strategies based on individual member needs and circumstances.
• Community Awareness: Understands how healthcare access, social needs, transportation, housing, food, and other factors can affect member outcomes.
• Independence: Works effectively without direct clinical supervision and knows when to seek leadership support or escalate concerns.
• Technology: Accurately utilizes required systems to document and track member activity.
• Teamwork: Contributes to a collaborative team environment while independently managing assigned responsibilities.

This is a field-based position that requires regular travel throughout the assigned service area and interaction with members in their homes and community settings.

The position may require:

• Frequent driving and travel within the assigned territory.
• Walking and navigating various community and residential environments.
• Sitting, standing, walking, and moving between field locations throughout the workday.
• Working independently in community settings.
• Use of a computer, mobile device, and telephone for documentation and communication.

The Community Health Navigator does not provide clinical care, diagnosis, medical advice, or treatment. The CHN supports members with healthcare navigation, engagement, education within the scope of the role, resource connection, appointment coordination, and identified care gap closure activities.

Clinical questions or concerns outside the Navigator's scope should be appropriately escalated to the Regional Manager or designated to the clinical/healthcare contact person.

Success in the Maryland Community Health Navigator role is demonstrated by the ability to consistently engage members, establish meaningful connections to primary care, address barriers to care, close identified care gaps, and help members achieve their goals within the program's short-term engagement period.

The CHN should be comfortable working in the field, independently managing their caseload, building relationships quickly, and maintaining accountability for measurable member and program outcomes.