Patient Care Navigator

About the role

You are supported to do your best work and make a meaningful impact every day. You will be part of a collaborative, physician-led team that works as one and puts patients at the center of everything we do. With a connected network of providers, care teams, and services across primary and specialty care, surgery centers, imaging, lab, and therapy, you are part of a system designed to deliver high-quality, coordinated care. Together, we create an environment where you can grow, contribute, and help improve the experience and outcomes for every patient we serve.

Responsibilities

• Serves as a key member of the interdisciplinary care team supporting high-risk and rising-risk patients within value-based care programs.
• Supports population health initiatives, quality measure performance, risk adjustment accuracy, and care coordination activities aligned with organizational value-based contracts.
• Performs pre-visit planning and chart preparation to support value-based care initiatives, including:
• Identification of care gaps and screenings needed per quality metrics (e.g., mammogram, DEXA scan, colorectal screening, immunizations)
• Review of open lab and imaging orders
• Preparation for Annual Wellness Visits (AWV) and High-Intensity Care (HIC) visits
• Review of recent hospitalizations or emergency department visits
• Schedules and coordinates Monthly HIC visits
• Specialist appointments
• Preventive screenings aligned with quality metrics
• Lab and imaging appointments
• Performs protocol-driven clinical monitoring to support chronic disease management and value-based quality outcomes.
• Obtains and documents vital signs including blood pressure, heart rate, respiratory rate, temperature, weight, BMI, and pulse oximetry.
• Performs point-of-care testing such as blood glucose monitoring and other ordered tests within scope.
• Conducts repeat blood pressure checks for patients with elevated readings.
• Collates and documents home monitoring data, including patient-reported blood pressure readings, glucose logs, weight logs (for heart failure monitoring), and pulse oximetry readings when applicable.
• Identifies abnormal findings and escalates to the Provider or Care Ally Nurse in accordance with established clinical protocols.
• Supports Value-based Quality Initiatives by tracking and following up on incomplete orders (labs, imaging, diagnostic testing), ensuring completion and documentation of preventive screenings, and assisting with quality audits and chart reviews as directed.
• Documents patient information including medications, reasons for visit, vitals, screenings, and structured quality data elements.
• Ensures lab, imaging, and diagnostic results are correctly documented and routed.
• Pulls discharge reports from hospital portals and obtains medical records from hospitals not utilizing Epic or shared EHR platforms.
• Completes documentation support for Transitional Care Management (TCM), Chronic Care Management (CCM), High-Intensity Care visits, and Annual Wellness Visits as directed.
• Administers and documents Social Determinants of Health (SDOH) screenings as applicable.
• Manages incoming communications, including managing incoming faxes, in-basket requests, and electronic communications in a timely and organized manner.
• Aids nurse and providers with medication refill workflows after appropriate review and approval.
• Coordinates communication with pharmacies and specialists as directed.
• Routes urgent or clinically significant communications to Provider or Case Management Nurse per protocol.

Requirements

• High school diploma or GED and completion of one of the following: Accredited Medical or Nursing Assistant Program or EMT-B or Equivalent experience.
• Preferred one-year experience in a medical setting such as a doctor’s office, hospital or long-term nursing facility.
• Must be experienced in PC/keyboard skills and Microsoft office applications.
• Must possess excellent communication and writing skills.
• Must have the ability to plan, organize, and work independently; exhibits problem-solving skills.
• Able to develop professional rapport with employees at all levels of the company.
• Must be able to perform CPR when necessary.
• Practices OSHA safety standards and complies with HIPAA at all times.

Qualifications

• High school diploma or GED
• Completion of one of the following: Accredited Medical or Nursing Assistant Program or EMT-B or Equivalent experience
• One-year experience in a medical setting such as a doctor’s office, hospital or long-term nursing facility preferred
• Experience in PC/keyboard skills and Microsoft office applications
• Excellent communication and writing skills
• Ability to plan, organize, and work independently; problem-solving skills
• Professional rapport with employees at all levels of the company
• Perform CPR when necessary
• OSHA safety standards and HIPAA compliance

Skills

• Medical Assistant
• Accredited Medical or Nursing Assistant Program
• EMT-B or Equivalent experience
• PC/Keyboard Skills
• Microsoft Office Applications
• Communication and Writing Skills
• Problem-Solving Skills
• Professional Rapport
• Perform CPR
• OSHA Safety Standards
• HIPAA Compliance

Benefits

• Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
• Access to a mental health benefit at no cost.
• Employer provided life and disability insurance.
• $5,250 Tuition Reimbursement per year.
• Immediate 401(k) match.
• 40 hours paid volunteer time off.
• A culture committed to community engagement and social impact.
• Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.

Pay

The compensation for this role includes a base pay range of $21.43-23.63 for a Medical Assistant; Certified or Registered Medical Assistant the base pay range is $22.97-24.57, with the actual pay determined by factors such as skills, experience, education, certifications, geographic location, and internal equity. Additional compensation may be available through shift differentials, bonuses, and other incentives. Base pay is only a portion of the total rewards package.

Schedule

Monday through Friday 8am-5pm