Care Navigator

This is a fully remote position, open to applicants in Texas.

📋 Description

• Perform proactive outreach to patients to uncover unmet social needs utilizing the nine-domain CMS-aligned SDoH assessment.

• Engage patients in goal-focused discussions to establish priorities, evaluate readiness, and cultivate rapport.

• Identify and document SDoH requirements across all nine domains.

• Research and connect patients with community resources, local programs, public benefits, and referral partners.

• Assist patients through application, referral, and enrollment processes.

• Follow up to confirm resource utilization, verify access, and achieve complete resolution of social barriers.

• Manage each SDoH case from initial identification to confirmed closure.

• Record interventions, follow-up communications, and resolution results in Pt. 360.

• Keep unresolved or partially resolved cases active and monitored.

• Facilitate timely closure of open SDoH cases and escalate any stalled cases.

• Collaborate with pod clinicians, including RNs, APPs, and BHCs.

• Escalate clinical, behavioral health, safety, or high-risk psychosocial issues.

• Participate in interdisciplinary huddles and discussions regarding complex cases.

• Track ongoing SDoH needs until resolution is achieved.

• Support internal quality improvement initiatives and SDoH data collection efforts.

⛳️ Requirements

• High school diploma or GED.

• A minimum of two (2) years of experience in care coordination, patient navigation, community health, or social services support.

• Proven communication and relationship-building abilities.

• Comfort in working with diverse populations and complex social needs.

• Capability to manage multiple priorities in a dynamic environment.

• Bachelor’s degree in public health, human services, social sciences, or related fields is preferred.

• Experience with Medicaid, Medicare, or value-based care populations is preferred.

• Familiarity with community resources and benefit programs is preferred.

• Bilingual language skills are preferred.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Employee assistance program.

• Employer-paid and voluntary life insurance.

• Disability insurance.

• Health and flexible spending accounts.

• 401k with employer match.

• Financial wellness resources.

• 20 PTO days.

• 7 paid holidays.

• 1 floating day.

• Paid parental leave.

• Work-life assistance resources.

• Physical wellness perks.

• Mental health support.

• Employee referral program.

• BenefitHub for employee discounts.