System Navigator

In collaboration with the interdisciplinary primary healthcare team, the System Navigator will work with patients and community partners to navigate the increasingly complex health care system, to ensure that all patients have equal and fair access to health care and essential social services and community resources. The role provides support and advocacy for patients and their families, by focusing on the social determinants of health which by working with all members of the MFHT and community partners, will address patient needs and facilitate access to necessary resources.

The SN will assess patients’ needs and goals in relation to social determinants of health; collaborate with patients, clinicians and community resources to address issues impacting social wellness; identify and access community resources and link patients through referral, advocacy and collaboration; participate in program development internally and with external partners to meet the needs where gaps are identified.

Working in this teaching environment, the System Navigator will participate in educational opportunities for family medicine residents and other health professional students. All team members participate in interdisciplinary team development, continuing education activities, primary health care research and is involved with system changes and improvements to enhance team and work processes and patient care.

Additionally, the SN will Initiate, participate, and/or lead programs, presentations, publications, evaluations and other system changes to continue the enhancement of interdisciplinary primary care teams.

1. Social Service Worker Diploma, or Degree in Health or Social Science field, with a minimum of two years relevant community work experience.
2. Experience assisting individuals in accessing, and extensive knowledge of, community resources, programs and services related to health care; employment, income, housing; mental health support; immigrant and refugee health.
3. Proven assessment and case management skills to assist patients in creating care goals and accessing resources and services to meet identified needs.
4. Excellent interpersonal, oral and written communication skills.
5. Demonstrated ability to exercise sound judgement and decision-making skills.
6. Proven relationship-building, community engagement and outreach skills.
7. Proven ability to work as a member of an interdisciplinary team.
8. Demonstrated initiative and experience working independently with minimal supervision.
9. Working knowledge of government programs and legislations (e.g., OW, ODSP, CPPD, WSIB, CYFSA).
10. Proficiency with Microsoft Office programs, electronic medical records, and ability to learn and master other computer programs as needed.