About Avenue360 Health and Wellness

Avenue 360 is a FQHC that strives to provide high quality and caring service to promote healthy people and communities. Our 360-degree approach addresses medical needs and social and environmental challenges, like housing. Our compassionate care extends to those with and without insurance. We believe income must not determine the level of access to quality health care.

Providing comprehensive, high quality, and caring service is the core of what we do, whether medical, hospice care, engaging adult activities, and supportive housing programs. We strive to address the many social determinants of healthy living in Greater Houston.

Our Values PACT

• We take PRIDE in our work.
• We have a positive ATTITUDE.
• We are CURIOUS.
• We are COMMITTED.
• We are CARING and CUSTOMER-SERVICE oriented.
• We are a TEAM.
• We LEARN, GROW, and INNOVATE

Overview: The Patient Navigator is a non-medical case management position on Avenue 360’s Social Services team and provides information, referrals, and assistance with linkage to Social Drivers of Health (SDOH) needs such as medical, mental health, substance abuse, housing, housing financial assistance, food, etc. for People Living with HIV/AIDS (PLWHA) and the agency’s general patient population. This position is also responsible for client advocacy to decrease service gaps and remove barriers to services by assisting clients to develop and utilize independent living skills and strategies. 

Duties and Responsibilities: 

• Acts as the main non-supervisory point of contact (telephone, email, walk-ins, etc.) for the Social Services Department for internal and external client, community, staff inquiries, and referrals (incoming & outgoing). 

• Communicates with others (internally and externally) to provide, exchange, or verify information, answer questions, and address issues of clients. 

• Routes to the appropriate party(s) to facilitate resolution of issues for clients, community members, and agency staff regarding social services related matters.  

• Provides information on the range of services offered by the social services team to clients and, if appropriate, his/her personal support team. 

• Develops rapport with colleagues and agency clinical staff to ensure that department workflows are performed effectively and efficiently. 

• Greets clients/patients awaiting services and maintains regular contact until service delivery occurs. 

• Provides “warm handoff” connections for clients/patients to other agency departments and service lines (e.g., pharmacy, finance, clinic, dietician, etc.).  

• Completes brief RWGA-approved assessments on clients within initial and follow-up prescribed timeframes. 

• Facilitates, where applicable, linkages to resources that address transportation barriers (ride sharing, bus cards, etc.), housing stability issues (financial assistance in the form of rent payments through Avenue 360), food insecurity, medical, etc. 

• Makes referrals to the Medical Case Management services team for more comprehensive assessments when clients present with more complex issues (e.g., mental health, substance abuse, and housing). 

• Documents services provided in client records, the Centralized Patient Care Data Management System (CPCDMS) database, and other database systems as instructed, if applicable. 

• Ensures data is entered into database systems within prescribed timeframes to satisfy requirements for chart closure and service billing requirements. 

• Compiles and analyzes data for weekly, monthly, quarterly, and annual reports as scheduled or as requested. 

• Participates in, at minimum, four (4) hours of individual and group clinical supervision activities each month. 

• Attend at least one (1) Joint Prevention and Care Coordination meeting each year. 

• Keeps abreast of new knowledge and techniques related to the practice of social work and new medical treatment modalities. 

• Maintain knowledge of internal and external service-related resources. 

• Perform other duties as assigned. 

Education and Job-Related Experience Minimum Requirements: 

• A bachelor’s degree from an accredited college or university, preferably with a major in social or behavioral sciences. 

• Note: Paid work experience in providing services to PLWH may be substituted for the bachelor’s degree requirement on 1:1 basis (e.g., 4 years of paid experience would be commensurate with a bachelor’s degree). 

• One (1) year of paid work experience in the provision of services to individuals living with HIV is required in addition to the degree requirement. 

• Must possess excellent oral and written communication skills. 

• Must be proficient in Microsoft Office Suite applications; experience with the CPCDMS and EHR database systems is also desirable. 

• Bilingual in English and Spanish highly desired. 

Continuing Education and Training Requirements: 

• Certified Application Counselor (CAC) certification must be obtained within 90-days of hire. 

• Participation in trainings required by the funding source and agency must be satisfied as de