The Lead Care Navigator (LCN) is responsible for coordinating all Native Wellness referrals and services for clients, and collaborates with internal departments and external resources to develop care coordination and referral plans to address social, economic, academic, familial, cultural, medical, and other issues that impact the clients’ functioning and well-being. This position will serve on integrated care teams and provide triage for referrals received in the Native Wellness Department. May transport clients, and assists with a variety of client activities based on treatment and referral plan needs. The LCN is part of a multi-disciplinary team, and the majority of services are provided in the Native Wellness Department, but may be required to work interdepartmentally on referrals. The LCN will manage and track all referrals from beginning to end for the programs within the Native Wellness department. The Lead Care Navigator also monitors performance metrics, identifies opportunities for process improvement, and provides training and support to enhance team efficiency and effectiveness. May manage case load when needed in the department. The ideal candidate will have experience working with the Native American Community and/or other minority groups.

 Essential Duties:

• Liaison integrated within all FAIHP departments to provide warm hand-off and/or linkage to resources and referrals
• Responsible for coordinating the services and referrals for each client assigned
• Administers brief client intakes to assess needs and make appropriate referrals
• Establishes a course of action by exploring referral options with the client
• Provides case management services to adults, youth, and families when needed
• Establishes and maintains rapport with local resource agencies
• May attend community partner meetings and client meetings (TDMs, CFTs, court hearings, etc.)
• Conducts community presentations and trainings as assigned
• Attends community outreach events as assigned
• Maintains appropriate documentation through the NextGen electronic health record system
• Monitors referrals regularly and provides ongoing follow-up with clients and providers
• Transports clients as needed for activities relating to the care coordination and treatment plan
• Completes monthly and annual reporting for grants and FAIHP requirements
• Provides feedback to care teams on care coordination issues
• Assists with data collection efforts
• Conducts data entry into electronic database that maintains client encounter information and referral information
• Keeps Supervisor well-informed regarding activities, pending issues, and potential problems  
• Adheres to agency policies and procedures and advances the goals of FAIHP in a manner that embodies the agency’s philosophy
• Maintains strict confidentiality of client and personnel information, adhering to HIPAA, professional codes of conduct, State of CA regulations, Privacy Act, and FAIHP policies and procedures
• Ensures that referrals are tracked, completed, and closed to avoid gaps in care
• Other duties as assigned or required to fulfill the purpose of the position
• Will provide administrative support by performing a large variety of tasks to support the Director of Native Wellness

Minimum Requirements                                             

• Bachelor’s degree from an accredited institution or equivalent preferred.
• Demonstrated experience of a minimum of 2 years in the provision of care coordination and/or case management services in a clinical or human service setting.
• Strong interest in providing culturally relevant services
• Demonstrate ability to communicate effectively and professionally, both verbally and in writing
• Demonstrate ability and willingness to work with culturally diverse populations, youth, and other community professionals.
• Knowledge of and/or sensitivity to the needs of the American Indian/ Alaska Native community.
• Valid California Driver’s license that is insurable on the company vehicle insurance policy.

A clear background check, a drug screen, and a negative TB test are required for employment.

FAIHP offers a robust benefits package that includes:

The Public Health Nurse (PHN) plays a vital role in promoting and protecting the health of individuals, families, and communities—particularly those who are vulnerable or underserved. This position emphasizes disease prevention, health education, case management, and community outreach, with a focus on addressing health disparities and improving outcomes across the lifespan. The PHN integrates nursing and public health principles in practice and collaborates with community partners to advance the health and well-being of Native Americans and other community members. Key responsibilities include the systematic analysis of health data, development of care plans, patient advocacy, delivery of health education, assistance in an ambulatory care setting, and case management for individuals with high service utilization.

ESSENTIAL DUTIES:

• Deliver high-quality, evidence-based nursing care to clients across the lifespan in alignment with FAIHP's purpose, vision, and values.
• Conduct comprehensive health screenings and risk assessments for adults, children, and women’s health, including chronic disease monitoring and prevention.
• Provide timely referrals for diagnosis and treatment and ensure continuity of care across providers and systems.
• Offer individualized and group health education aligned with public health goals and regulatory requirements (HEDIS, GPRA, CalAIM, etc.).
• Conduct in-person health evaluations, screenings, education sessions, and home visits as required by IHS contracts or other funding sources.
• Deliver culturally responsive health information to promote understanding of local public health policies, health risks, and available services.
• Assist in the clinic as needed, including supporting patient flow, providing direct nursing care, and collaborating with clinical staff to ensure efficient and high-quality service delivery.
• Collaborate with case management staff to support client navigation of primary and specialty care services.
• Ensure care coordination and follow-up for high-risk or vulnerable clients, evaluating the effectiveness of care plans and adjusting as needed.
• Accurately document encounters in the NG Practice Management/EHR system and monitor population-level outcomes using available reporting tools.
• Track and report performance indicators related to service delivery and clinical outcomes.
• Support FAIHP’s education and workforce development initiatives by supervising and mentoring student nurse externs, providing guidance, training, and oversight in clinical and community settings as assigned.

• Prepare and submit timely reports and required documentation for internal use and external regulatory agencies, including IHS, Public Health, VFC, and others.
• Participate in departmental performance evaluation and quality improvement activities.
• Keep the Director of Operations informed of program updates, potential concerns, or emerging issues.
• Advocate on behalf of clients to support access to health and community resources.
• Perform other related duties as assigned, including participation in organizational initiatives, special projects, or emergency response efforts as needed.

MINIMUM REQUIREMENTS                                       

EDUCATION:

• Required Bachelor of Science in Nursing (BSN) from an accredited school or university.

EXPERIENCE:

• Required 3 years of prior experience in a lead capacity or preferred supervisor responsible for team productivity.
• Preferred experience working with Native American communities is preferred.

LICENSE/CERTIFICATIONS REQUIRED:

• CA RN License in good standing
• Certification in Public Health Nursing
• Active CPR certification
• Active CA driver’s license required for role
• Knowledge of population-based health status indicators, determinants of health and illness, factors contributing to health promotion and disease prevention, and factors affecting the use of health services.

SKILLS:

• Knowledge of and/or sensitivity to the needs of the American Indian community/culture.
• Demonstrate ability or willingness to work with culturally diverse populations, youth, and professionals.
• Demonstrate ability to communicate effectively and professionally both verbally and in writing.
• Ability to effectively manage multiple priorities.
• Strong data collection and data analysis skills.
• Availability to work evening and weekend hours as required.
• Familiarity with concepts and processes associated with implementation science.

A clear background check, drug screen, and negative TB screen are necessary for employment.

FAIHP offers a robust benefits package that includes:

• Health Insurance

• Dental Insurance

• Vision 

• Life Insurance

• 403(b) retirement

• Vacation 

• Sick

• 16 paid holidays per year

Complete FAIHP Employment Application by visiting our website at www.faihp.org