Patient Care Navigator

This role serves as a vital bridge between medical practitioners, facility staff, patients, and their families, ensuring seamless patient transitions of care across health settings. By combining administrative medical support, transition management, and patient advocacy, the navigator promotes high-quality, relationship-based support that is patient- and family-centered.

Responsibilities

• Collaborate with patients, families, and multidisciplinary medical teams to support transitions to the next level of care, including setting up follow-up appointments.
• Perform chart creation and data entry of patient demographics, medications, and diagnoses within the EMR system.
• Assist with transition clinic services, patient intake, phone calls, and documentation.
• Conduct patient social risk factor assessments to identify unmet health or social needs.
• Identify high-risk, complex patients who would benefit from transition services, chronic disease management, or remote monitoring, and assist them with enrollment.
• Serve as a reliable point of contact and advocate for the patient.
• Attend IDT (Interdisciplinary Team) plan of care meetings at facilities and communicate daily with practitioners and Nurse Case Managers.
• Assist in the collection of key quality metrics and program performance improvement data.

Requirements

• High school diploma or equivalent (required).
• Graduate of an accredited Medical Assistant program (required).
• Certified Medical Assistant (CMA) is highly preferred.
• Current Basic Life Support (BLS) Certification.
• Minimum of 1 to 3 years of proven experience with EMR/EHR systems and taking vital signs.
• 5–7 years of experience in Skilled Nursing Facilities.
• Strong knowledge of medical terminology.
• Ability to travel to Jefferson & Clinton (Wisconsin).

Skills

• Excellent bedside manner, problem-solving abilities, and communication skills.
• Deep compassion for patient care, particularly when working with medically complex older adults.

Benefits

• 401(k) with company matching
• Comprehensive Health, Dental, and Vision insurance
• Health Savings Account (HSA)
• Life insurance
• Generous Paid Time Off (PTO)
• Travel reimbursement for community/facility travel

Pay

$21.50–$30 per hour

Schedule

Full-time, 8-hour shift, Monday to Friday

About Us

Community Physicians is a dedicated, multi-specialty medical group focused on providing exceptional, relationship-based care to older adults in skilled nursing and post-acute settings. Our mission is to improve health outcomes, enhance care transitions, and preserve the dignity of every patient we serve.

Why Join Us?

• Purpose-Driven Work: Play a vital role in caring for medically complex older adults during their most vulnerable health transitions, directly impacting patient outcomes, reducing hospital readmissions, and improving quality of life.
• Collaborative and Supportive Environment: Work closely with facility staff, families, and interdisciplinary teams to ensure seamless, compassionate, and coordinated care.
• Clinical Excellence and Innovation: Prioritize evidence-based practices and continuity of care, bringing clinical excellence to every bedside.
• Professional Growth and Leadership: Opportunities to lead, innovate, and contribute to the growth of geriatric care in our community, with investment in professional development.
• A Culture of Compassion and Respect: Part of a team that values dignity, empathy, and respect for both patients and staff.