The Patient Navigator works independently as a liaison between the Care Transitions Patient Navigator, Care Transitions Coordinator, TVHC and local hospital staff. With oversight from the Care Transitions Coordinator, the CHW identifies and assists the patient in accessing community resources and is the primary linkage to local Community Health Centers and programs. The CHW will employ effective interpersonal skills in order to coordinate the best outcomes for patients. A strong candidate possesses skills in systems navigation, to ensure patients return to their primary care setting while addressing social determinant related issues which create barriers to accessing ongoing health care. The Care Transitions CHW’s primary responsibility is patient engagement which happens on the phone, at a clinic or hospital setting and in patient’s home. Candidate must feel comfortable working with patients to address complex needs, patient advocacy, communicating with medical providers and data collection.