Community Navigator (150 views)

Los Angeles, CA
September 21, 2021 2021-11-20
Job Description

Schedule: Variable. Requires flexibility to accommodate program needs.

Benefits: Medical, Vision, Dental, Life Insurance, 403(b) Retirement plan, Eligibility for Student Loan Forgiveness, Employee Resource Groups


Under the supervision of the Director of Community Nursing at The People Concern and Kaiser Permanente West LA Management, the Community Navigator will:

  1. Utilizing a harm reduction model, serve to improve the follow-up care and services provided to homeless patients at discharge by assessing patients’ needs and connecting them with the appropriate resources.
  2. In conjunction with Social Work staff, create a Community Resources list/binder on services available for the homeless population.
  3. Build effective working relationships with hospital staff to educate staff on the services available to this population and resources available within the Community to assist individuals experiencing homelessness. Ensure resources are up to date and effectively utilized.  Participate in specified meetings to help disseminate this information among all staff involved in caring for individuals experiencing homelessness as determined by management.
  4. Responsible for making sure that KP West LA patients benefit from all available community programs by keeping staff informed and taking initiative to refer, track, which community resources are provided.
  5. Work as part of a team to coordinate directly with social service agencies throughout LA County to connect homeless patients to appropriate housing and services, including referrals to various housing programs.
  6. Design and implement strategies for engaging individuals who resist services in collaboration with KP staff at KP West LA and other facilities.
  7. Create and maintain a list of high needs patients with Kaiser Homeless Task Force
  8. Work closely with hospital staff (inpatient and emergency department) to contribute to discharge plans to ensure continuity of services by connecting to case management and other recommended services after release from the hospital.  
  9.  Schedule follow-up medical appointments by making PCP appointments and documenting appointments in Health Connect.
  10. Maintain a cooperative relationship among care teams with both inpatient and Emergency Department staff by communicating information, responding to requests, building rapport, participating in team problem-solving efforts.
  11. Follow hospital accreditation standards of care by maintaining database and detail-oriented documentation of the services provided for each patient and must complete Homeless Discharge Form with each patient.
  12. Be thoroughly familiar with the policies and procedures guiding the work of this program and general hospital overall. Perform job functions in line with these policies and procedures.
  13. Participate in regular team meetings, and training sessions required by KP WEST LA and TPC.
  14. Participate in all safety programs and trainings required by KP WEST LA and TPC. 
  15. Maintain professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks, and participating in professional societies, as appropriate.
  16. Maintain strict confidentiality and privacy practices and share information, as appropriate and legally allowed, to coordinate patient care.
  17. Maintain a safe and clean working environment.
  18. Other duties as assigned.


  • Demonstrate ability to interface with community agencies and providers outside MDRH.
  • Experience working as part of a health care team.
  • Minimum of one (1) year of experience working with homeless and/or underserved populations.
  • Knowledge of healthcare systems.
  • Significant experience working with persons experiencing homelessness and having complex needs, conducting assessments of general patient information, developing short-term care plans and providing necessary interventions identified during assessment.
  • Previous experience working with persons experiencing severe and persistent mental illness (SMPI) and polysubstance abuse.
  • Able to work evenings and weekends.
  • Computer skills including Word, Excel and Outlook.
  • Ability to work well as part of an interdisciplinary team.
  • Excellent verbal and written communication skills.
  • Excellent charting/documentation skills and data collection.
  • Passion for and commitment to working with underserved and indigent populations.
  • Ability to work well with culturally diverse clientele, including LGBTQ individuals and those living with disabilities, serious mental illness and substance use disorders.
  • Skilled in non-violent crisis intervention.
  • Ability to self-motivate, multi-task and be flexible in a fast-paced environment.
  • Must successfully pass fingerprinting at start of employment.

Education Requirements:

  • BA or BS strongly preferred; or two years’ experience in medical case management or homeless services.
  • Bilingual (Spanish/English) strongly preferred.


Valid CA Driver’s License and car required for travel when needed to carry out job-related duties

The People Concern is an equal opportunity employer dedicated to non-discrimination in employment. We select the most qualified individual for the job based on job-related qualifications regardless of race, color, age, sex, religion, national origin, disability, ancestry, marital status, credit history, sexual orientation, arrest and court record, genetic information, veteran status or any other status protected by federal, state or other applicable laws.