Community Resource Navigator (Social Work)

Big Bend Palliative Care (formerly Transitions Supportive Care), a program of Big Bend Health, is dedicated to improving quality of life for individuals living with serious illness through compassionate, community-based support. Guided by our values of respect, excellence, integrity, accountability, and compassion, we are seeking a Community Resource Navigator (CRN) to support patients and caregivers in accessing essential resources and navigating complex care systems.

The ideal candidate for the Community Resource Navigator role is a compassionate and resourceful social work professional who is passionate about supporting patients and families facing serious illness. This individual excels in communication, care coordination, and problem-solving, with a strong understanding of community resources and social drivers of health. They will play a critical role in supporting Principal Care Management (PCM) services through patient outreach, resource coordination, and care plan follow-up, while also serving as a mentor to interns and a key member of the interdisciplinary team.

The Community Resource Navigator responsibilities include, but are not limited to the following:

• Conduct outreach to assigned patients and caregivers within 72 hours of referral (or next business day for weekend referrals).
• Assess patient and caregiver needs, identify barriers to care, and support care plan follow-up.
• Coordinate community resources including transportation, housing, food assistance, utilities, and in-home support services.
• Assist patients and caregivers with benefit applications such as Medicaid, long-term care services, and other public assistance programs.
• Provide in-person or virtual support, including psychosocial and social needs assessments.
• Educate caregivers on coping strategies, self-care, and available community supports.
• Maintain and update community resource lists.
• Support patient engagement and continuity of care by assisting with follow-through on appointments, services, and applications.
• Communicate patient needs, barriers, and changes in condition to appropriate clinicians and team members.
• Collaborate with interdisciplinary team members, community partners, case managers, and providers.
• Support operations on the mobile medical unit as needed.
• Maintain accurate, timely, and compliant documentation in the electronic medical record and program trackers.
• Track outreach, interventions, and follow-up activities to support PCM program goals.
• Submit weekly productivity reports to leadership.
• Supervise and support MSW interns, including training, task delegation, and performance feedback.
• Complete required internship evaluations and documentation.
• Participate in program development, quality improvement, and professional development initiatives.
• Maintain confidentiality and comply with HIPAA and organizational policies.
• Perform other duties as assigned.

• Typically Monday–Friday, standard business hours.
• Full-time position; schedule may vary based on program and patient needs.

You must have a reliable vehicle and be willing to travel within the Big Bend service area to support patients, caregivers, and community partnerships.

Education & Experience:
• Master’s Degree in Social Work (required).
• Minimum of three (3) years of experience supporting patients and/or caregivers coping with serious or advanced illness.
• Experience navigating community resources, social services, and benefit programs.
• Prior experience supervising students or interns preferred.
• Intermediate computer skills required.

Skills & Abilities:
• Strong communication and interpersonal skills.
• Ability to manage multiple priorities with attention to detail.
• Strong problem-solving and critical thinking skills.
• Ability to work independently and collaboratively within a team.
• Knowledge of social drivers of health and their impact on patient outcomes.
• Ability to maintain professionalism in stressful or emotionally sensitive situations.
• Proficiency in Microsoft Office and electronic medical record systems.

• Valid driver’s license, auto insurance, and reliable transportation.
• Commitment to Big Bend Health’s core values: respect, excellence, integrity, accountability, and compassion.

Big Bend Health offers a robust Total Rewards package including Competitive Salary, Comprehensive Benefits, Recognition Programs, and Public Service Loan Forgiveness eligibility (for most roles).

Apply today and help us expand access to compassionate, community-based care while supporting patients and families through every step of their journey.

Big Bend Health is an equal opportunity employer committed to diversity and inclusion.