Community Health Navigator - NJ

Position Title: Community Health Navigator - Complete Connect Program (New Jersy) 

Department: Operations

Reports To: Territory Manager

Location: Field-Based (community settings)

Employment Type: Full-time

Travel requirement: This is a field-based position and requires daily travel throughout the assigned community territory. 

About MedZed 

MedZed delivers value-based, technology-enabled social support to high-cost Medicaid members who have been unreachable through traditional telephonic outreach, disconnected from primary care, and frequently rely on hospital-based services as their primary point of care. We combine innovative technology with field-based outreach to engage members, reconnect them to appropriate healthcare providers, address Health-Related Social Needs (HRSNs), and empower members to take greater control of their health.

Our interventions are designed to reduce avoidable Emergency Department and Inpatient utilization while improving health outcomes and quality of life.

Primary Focus: 

The Community Health Navigator (CHN) is responsible for finding, locating, engaging, and enrolling eligible members and providing ongoing field-based support throughout their participation in the program.

Once a member is enrolled, the CHN develops a trusted relationship with the member, addresses social and healthcare needs, connects the member to appropriate providers and community resources, closes identified care gaps, and supports the member in achieving their care plan goals.

The goal is to successfully engage and prepare each member for graduation from the program within a six-month enrollment period.

Position Overview:

The Community Health Navigator (CHN) is a highly visible, field-based role responsible for managing a consented caseload of 45–55 members.

CHNs will spend most of their workday in the community conducting outreach and member visits. The role requires the ability to independently locate members, establish rapport, obtain informed consent, assess needs, coordinate services, and maintain consistent engagement throughout the member's enrollment.

The CHN works closely with the internal clinical team to address identified needs, escalate high-risk concerns, and support members in achieving measurable health and social outcomes.

Success in this position requires strong organizational skills, reliable follow-through, effective communication, and the ability to manage competing priorities while meeting established program goals, performance expectations, and Service Level Agreements (SLAs).

Key Responsibilities:

Member Outreach & Enrollment

• Identify, find, and locate eligible members through field outreach, community canvassing, telephone outreach, and other approved outreach strategies.
• Conduct face-to-face outreach in hospitals, members' homes, community locations, and other appropriate settings.
• Establish rapport and build trust with members who may have previously been difficult to reach.
• Explain the program and obtain informed member consent prior to enrollment.
• Complete required enrollment and assessment activities accurately and timely.
• Maintain a consistent pipeline of potential members to support program enrollment goals.

Caseload & Member Engagement

• Manage and maintain a consented caseload of 45–55 members.
• Maintain successful engagement with members throughout the entire enrollment period. Members should have at least two successful contacts per month. 
• Develop individualized relationships and support members in achieving their care plan goals.
• Conduct timely and consistent follow-up based on member needs, risk level, and program requirements.
• Monitor member progress and identify barriers that may interfere with successful program completion.
• Re-engage members who become difficult to reach and use appropriate outreach strategies to maintain participation.
• Prepare members for successful graduation from the program within the six-month enrollment period.

Social Determinants of Health & Community Resources

• Assess and address Health-Related Social Needs (HRSNs), including:
  • Housing
  • Food insecurity
  • Transportation
  • Utilities
  • Behavioral health
  • Financial and community resource needs
• Connect members with appropriate community-based organizations and resources.
• Follow up to ensure members are successfully connected to referred resources and services.
• Identify barriers to care and work collaboratively with members to develop solutions.

Healthcare Navigation & Care Gap Closure

• Connect members to primary care providers, specialists, and other appropriate healthcare services.
• Assist members with scheduling appointments and provide follow-up to support appointment completion.
• Identify, address, and close assigned healthcare gaps in collaboration with the clinical team.
• Educate and coach members on the importance of preventive care and ongoing healthcare engagement.
• Support members in establishing and maintaining relationships with appropriate healthcare providers.
• Document health metrics, including blood pressure readings and A1C (ALC) numbers, when applicable.
• Monitor member progress toward identified health and care plan goals.

Hospitalization & Transitions of Care Support

• Monitor member hospitalizations when information is available.
• Provide timely follow-up when a member is hospitalized or discharged.
• Coordinate with the internal clinical team regarding hospitalized or high-risk members.
• Re-engage members following hospitalization or an Emergency Department visit.
• Assist members with reconnecting to providers and community resources following hospitalization.
• Escalate clinical, behavioral health, safety, or other high-risk concerns to the appropriate RN or clinical team member.

Documentation & Compliance

• Document all member encounters, outreach attempts, interventions, referrals, and outcomes accurately and within required timeframes.
• Maintain complete and timely documentation in the designated electronic system.
• Record required member health metrics and program activities.
• Ensure documentation supports program reporting, quality requirements, and member outcomes.
• Maintain confidentiality and comply with all organizational, client, and regulatory requirements.

Program Performance & Accountability

• Consistently support and contribute to established program goals and performance metrics.
• Meet established Service Level Agreements (SLAs) and productivity expectations.
• Maintain an organized daily schedule that prioritizes member needs, outreach, follow-up, and required documentation.
• Participate in team meetings, case conferences, training, quality improvement initiatives, and program activities.
• Communicate barriers, trends, and opportunities for improvement to the Territory Manager. 
• Demonstrate accountability for assigned caseload, member outcomes, engagement, documentation, and program deliverables.

Preferred Clinical & Community Health Background

We are seeking candidates with strong community health, healthcare navigation, outreach, or clinical support background. Ideal candidates may include individuals with experience or certification such as:

• Certified Nursing Assistant (CNA)
• Certified Medical Assistant (CMA)
• Patient Care Technician (PCT)
• Community Health Worker (CHW)
• Care Coordinator or Care Navigator
• Behavioral Health Technician
• Home Health Aide (HHA)
• Public Health or Health Education professional

Equivalent experience in community outreach, care coordination, case management, member engagement, healthcare navigation, or community-based healthcare programs will also be considered.

Qualifications:

• High school diploma or equivalent required.
• Community health, healthcare, outreach, or care coordination background strongly preferred.
• Experience working with Medicaid populations, healthcare navigation, community outreach, or social service programs preferred.
• Strong communication, relationship-building, motivational interviewing, and problem-solving skills.
• Ability to establish trust and effectively engage hard-to-reach members.
• Comfortable working independently in community settings.
• Strong organizational skills with the ability to manage a caseload of 45–55 members.
• Ability to prioritize daily activities and meet established productivity, program, and SLA expectations.
• Strong attention to detail and commitment to timely documentation and follow-up.
• Proficiency with electronic documentation systems and basic technology.
• Ability to work collaboratively with RNs, Territory Managers, providers, community organizations, and other members of the care team.
• Commitment to member-centered care, accountability, quality, and successful program outcomes.

Travel & Field Requirements

• This is a field-based position; regular community presence is an essential function of the role.
• Valid driver's license required.
• Reliable transportation required.
• Proof of active automobile insurance required.
• Ability to travel daily throughout the assigned territory.
• Ability to conduct visits in members' homes, hospitals, healthcare facilities, community organizations, and other approved locations.
• Ability to work independently while maintaining communication with the internal team.
• Flexibility to adjust daily routes and schedules based on member needs and program priorities.

Success in This Role

Success as a Community Health Navigator means more than completing outreach attempts. The CHN is accountable for finding and enrolling members, maintaining meaningful engagement, completing timely follow-up, addressing barriers to care, closing care gaps, supporting members through healthcare transitions, and preparing members for successful graduation from the program within six months.

The ideal candidate is proactive, organized, community-focused, comfortable working in the field, and committed to following through on every member interaction while consistently meeting program goals and SLA requirements.

Physical Requirements