Oak Street Health takes a team-based approach to providing outstanding patient care. We are building a new multidisciplinary Kidney Navigator Team consisting of a Medical Director, Nurse Practitioners, Community Health Workers, and Clinical Information Specialists. These specialized care teams will build individual relationships across a small panel of patients to better plan and coordinate care for patients with Chronic Kidney Disease, with the goal of improving clinical outcomes and the care experience for our patients.

Community Health Workers are an important part of our Kidney Navigator Program. A Community Health Worker is a patient’s advocate and liaison for their specific needs related to their Chronic Kidney Disease. Building trust and promoting encouragement are two of their key objectives. High levels of flexibility, attention to detail, and problem solving are required to be successful. You will be expected to build relationships with Oak Street Health patients, assist with managing patients’ care plans, perform proactive phone and in-person outreach to our patients based on their care needs, support Care Team decision making, participate in weekly care team meetings, and coordinate clinical and complementary services needed to provide a high quality health care experience between patients’ Oak Street Health care team as well as their external specialists and care sites. Community Health Workers will report to a Kidney Navigator Program Nurse Practitioner.

Core Responsibilities:

Work with the Nurse Practitioner to help enroll and orient patients to the Kidney Navigator Program

Identify key needs to ensure the patients’ success and coordinate services and solutions to address those needs

Develop trusted relationships with patients by providing support and advocacy to help achieve health goals

Meet with patients in patient-centered and patient-preferred locations (e.g., Oak Street Health center, facility, home, community setting)

Promote goal setting with patients enrolled in the program

Drive engagement with patients (e.g., completed specialty appointments, adherence to post-discharge plans, adherence to medication regimen), which may include accompaniment to appointments

Assist completion of applications to access eligible benefits

Wellness checks in home, participate in tele-visits, provide education on optimal lifestyle for chronic kidney disease management

Provide basic health screenings, referrals and information

Deliver health education presentations

Facilitate communication between all identified parties for the patient involved in care (e.g., family members, caregivers, medical providers, community-based organizations).

Document interactions with patients in medical record

Other duties, as assigned