Patient Care Navigator II (One Health Complete)

Key Responsibilities

• Partner with the SNF Social Worker and admissions team to coordinate intake on new admissions flagged by OHC
• Describe the OHC multispecialty care program to patients, obtain consent, and set patient and family expectations
• Schedule the qualifying home televisit and chart-review encounters between the patient and the OHC remote clinicians
• Gather information about patients across OHC and SNF EMRs
• Maintain accurate documentation of patient touchpoints, consent, and discharge instructions inside OHC’s EMR
• Interact with patients bedside at SNF to assess and educate about OHC
• Serve as the trusted on-site liaison between the SNF interdisciplinary team (Social Work, DON, Rehab, Pharmacy, etc.) and OHC’s care management team
• Surface workflow friction, facility-level adoption barriers, and patient-experience gaps to OHC leadership
• Manage and nurture PCN level I’s who are managing their own SNFs while managing your own
• Engage in continuous process improvement to the PCN workflow and role structure

Core Competencies

• High autonomy and sound judgment in an embedded, single-resource role
• Strong relationship-building skills with SNF Social Workers, DONs, and Co-Medical Directors
• Comfort with technology-forward workflows: AI alert dashboards, real-time data feeds, and digital consent
• Excellent verbal and written communication, including SBAR-style clinical escalation
• Mission alignment with closing the post-acute care cliff and improving access to care

Physical & Schedule Requirements

• On-site presence at the assigned SNF five days per week, with occasional flexibility for discharge timing
• Travel between Barrington and Huntley, IL
• Reliable transportation between the assigned SNF and occasional OHC team meetings