CARE NAVIGATOR JOB DESCRIPTION

Care navigation is a defined function in value-based care contracts: someone must own the gap between what a patient's care plan requires and what actually happens. When that ownership is unclear, patients miss follow-up appointments, medication adherence drops, and payers withhold quality-based reimbursements tied to HEDIS and Stars measures. The Care Navigator holds that ownership across a panel of assigned members, coordinating directly with interdisciplinary teams that include RNs, nurse practitioners, pharmacists, and social workers. Most positions require familiarity with transitional care management protocols and experience working within electronic medical record platforms central to population health workflows.

As the Care Navigator, you bridge member outreach, care coordination, and quality documentation to ensure patients with open care gaps receive timely interventions that support both clinical outcomes and value-based contract performance. You will operate within a multidisciplinary care team, supporting clinical staff by managing member communications, scheduling, referral coordination, and accurate documentation across a defined patient panel.

Career Impact: Hands-on experience with HEDIS gap closure and VBC quality programs builds direct expertise that is in demand as health systems accelerate their shift to value-based reimbursement models.

Business Impact: The patients in your assigned panel depend on your outreach to close preventive care gaps, coordinate specialist referrals, and ensure post-discharge follow-through that reduces unnecessary ER utilization.

Growth Opportunity: This role creates a direct path toward a Care Manager or Population Health Specialist title, particularly for those who pursue CCM certification or advance their clinical credentials while working within managed care workflows.

• Conduct proactive telephonic and video outreach to assigned member panels to identify care gaps and coordinate timely interventions.
• Collaborate with interdisciplinary care teams, including RNs, pharmacists, and social workers, to support personalized care plan development and execution.
• Manage transitional care management workflows by completing follow-up contacts with patients discharged from acute or post-acute facilities.
• Coordinate specialist referrals, laboratory orders, and diagnostic scheduling in alignment with physician and care team direction.
• Document all member encounters, referral authorizations, and care coordination activities accurately and within required timeframes in the electronic medical record.
• Monitor payer attribution lists and quality metric reports to identify members with unmet care needs and communicate gap status to clinical staff.
• Support utilization management by tracking ER utilization patterns and escalating cases requiring clinical review to the appropriate care manager.
• Facilitate member education on health plan benefits, preventive care resources, and available community support services.

• Bachelor's degree in health sciences, social work, public health, or a related field, or equivalent work experience.
• 3 or more years of experience in care coordination, case management, or population health, with demonstrated exposure to managed care or value-based care programs.
• Knowledge of medical terminology sufficient to communicate accurately with clinical team members and document patient encounters.
• Experience with transitional care management protocols, including post-discharge outreach and care plan follow-through.
• Proficiency in electronic medical record platforms for documentation, scheduling, and care gap tracking.
• Strong telephonic communication and motivational interviewing skills, with the ability to engage diverse patient populations effectively.
• Certified Nursing Assistant, Licensed Practical Nurse, or Medical Assistant certification, or active enrollment in a clinical training program preferred at this level.
• Ability to work independently, manage a high-volume member panel, and prioritize competing tasks in a metric-driven environment.

• Certified Case Manager (CCM) credential from the Commission for Case Management or eligibility to pursue within the first year.
• Prior experience with Medicaid populations or CMS compliance requirements in a managed care organization.
• Bilingual proficiency in English and a second language relevant to the patient population served.
• Familiarity with value-based care payer portals and Stars or HEDIS quality measure frameworks.

• Care gap closure rate per assigned member panel, reflecting the percentage of open quality measures resolved within the contract period.
• Transitional care management contact completion rate within 48 hours of facility discharge, per CMS program requirements.
• First-call resolution rate on inbound member inquiries, measuring how often navigation needs are addressed without escalation.
• ER utilization rate among assigned panel members, tracking whether outreach and care coordination interventions reduce avoidable ED visits.
• Documentation timeliness rate, measuring the percentage of encounters entered within required timeframes per accreditation and contractual standards.
• Typical tools: Electronic medical record platforms (commonly Athena, Epic); care management systems (commonly JIVA, CCMS).

• Base Salary Range: $42,000 to $62,000 annually, depending on clinical certification and experience
• Bonus: Performance-based bonus tied to quality metric targets, typically 3% to 7% of base
• Equity: Typically not offered at this level in managed care or health system settings
• Health Benefits: Medical, dental, and vision coverage; employer contributions vary by organization size
• PTO: 15 to 20 days annually, plus standard federal holidays
• Common Perks: Continuing education support, clinical certification reimbursement, mileage or transportation stipend where field-based travel is required

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Employment is contingent on successful completion of a background check and, where applicable, drug screening consistent with healthcare facility requirements. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status, or any other characteristic protected under applicable federal, state, and local law. Applicants requiring a reasonable accommodation to participate in the hiring process should notify the hiring team at the time of application. Candidates must be authorized to work in the United States.

The Care Navigator owns care management support for value-based care contracts by conducting chart reviews, gap closure attestations, and outbound patient outreach to improve quality metrics and health outcomes. Working alongside the Population Health Team and reporting to a supervisor, this role enables clinics to act on accurate, timely payer data while advancing cost reduction and preventative care goals.

Key Responsibilities

• Conduct chart reviews, data entry, documentation, and attestation submissions for value-based care gap closures.
• Collaborate with the Population Health Team to identify barriers and develop solutions to meet quality metric targets, reduce costs, and improve health outcomes for patients.
• Support clinic initiatives for care delivery interventions and outreach to patients with gaps in care, as needed.
• Communicate quality metric notifications to providers and practice teams via EMR.
• Conduct outbound calls to pharmacies and/or patients regarding medication adherence.
• Outreach specialists for consult notes, as needed.
• Review payer patient lists to supply clinics with the most up-to-date information on patients with open gaps.
• Manage daily distribution of the transitional care management patient file to clinics and upload monthly patient attribution to CORHIO.

Required Qualifications

• LPN License or Medical Assistant Certificate preferred.
• 3+ years of experience in population health, care management, or a related healthcare field.
• Knowledge of value-based care programs, quality measure specifications, and payment methodologies.
• Competent in triaging patients over the phone.
• Strong computer skills, particularly Microsoft Word and Excel.
• Working knowledge of health information technology and comfort learning new applications or databases.
• Experience with Athena EMR and Value-Based Care payer portals preferred.

Embedded within an innovative pilot mental health clinic built through a community college and medical school partnership, the Care Navigator delivers coaching, community outreach, and case documentation to expand mental health access for young adults. Working closely with community partners, agency staff, and diverse client populations, this role builds the infrastructure of a first-of-its-kind clinic by connecting clients to services and sustaining funder-required performance outcomes.

Core Functions

• Assist in skill-building through coaching and one-on-one work with young adults.
• Advocate and assist with problem-solving that will help the client access and utilize mental health supports and services.
• Conduct community outreach and develop relationships with diverse community members and organizations.
• Maintain regular communication with community partners.
• Attend agency staffings, team meetings, and other meetings/appointments as assigned.
• Complete necessary reporting requirements and ensure achievement of performance measures for funders and stakeholders.
• Maintain written documentation for all therapy services rendered, including initial assessments, follow-up visits, and discharge summaries.

Qualifications & Experience

• High School Diploma with 5 years of community/health-related experience, or Bachelor's Degree in a related field.
• Experience working with young adults from diverse backgrounds, including people experiencing homelessness, formerly incarcerated individuals, and people with disabilities.
• Knowledge of community-based resources including health and social services.
• Strong computer skills with the ability to document services clearly and effectively.
• Excellent interpersonal, written, and verbal communication skills, including community engagement and ability to reconcile differences.
• Strong customer service mindset when working with internal and external partners.
• Ability to work independently and as part of a team.
• English proficiency required.

Reporting to clinical leadership, the Care Navigator shapes personalized, preventative care for an assigned patient cohort by coordinating with physicians, tracking member engagement metrics, and following up after appointments to close care gaps. Partnering with clinical staff and health plan operations, this role improves patient experience and health outcomes while enabling the health plan to reduce unmet care needs across its member population.

Primary Duties

• Ensure patients of your cohort have great experiences seeking and receiving care.
• Encourage patients to engage more with their health by providing tools needed to embrace healthy lifestyle behaviors.
• Work with physicians and other clinical staff to administer personalized, preventative care.
• Optimize care and health outcomes of your member cohort.
• Support operations of the practice by assisting with care coordination.
• Suggest and develop metrics to track member engagement and identify members with unmet healthcare needs.
• Improve patient experience by anticipating care interventions before they arise.
• Educate patients on components of their health plan and answer relevant questions.
• Follow up with patients after appointments to assist with next steps and ensure all needs have been met.
• Manage patient communications and answer messages in a timely manner.

Skills & Qualifications

• Bachelor of Science in Nursing required.
• RN or LVN with active license, or 3+ years of experience in case management/care navigation.
• CCN or similar licensure preferred.
• 2+ years of experience in nursing, or 4+ years in healthcare, hospitality, or customer service.
• At least 1 year of experience working in a clinical setting.
• Knowledge of medical terminology and health plan components.
• Familiarity with phlebotomy and/or injections.
• Proficiency with Electronic Health Records and standard computer programs.
• Strong interpersonal, written, and verbal communication skills with outstanding attention to detail.
• Ability to speak a second language is an asset.

Sitting at the intersection of care coordination and patient education, the Care Navigator supports patients with physical, developmental, and intellectual disabilities through regular telephonic and televideo visits, specialist referrals, and cross-team collaboration. Operating across an interdisciplinary care team that includes RNs, NPs, pharmacists, and social workers, this role enables comprehensive, organized care delivery while maintaining accurate documentation across high volumes of patient interactions.

Duties

• Check in with patients regularly to identify immediate care needs and assist with disease education and care coordination.
• Schedule patients with other interdisciplinary care team members as necessary.
• Arrange prescribed laboratory tests, specialist referrals, and diagnostic procedures.
• Provide day-to-day support to the assigned care team, including RNs, NPs, pharmacists, and social workers.
• Communicate with patients about their condition through email, phone, and video conversations.
• Manage large volumes of inbound and outbound inquiries and document all correspondence accurately, targeting first call resolution.

Requirements

• Certified Nursing Assistant, Medical Assistant, or Licensed Practical Nurse certification preferred.
• 3+ years of experience in a healthcare environment.
• Experience with care coordination for patients with physical, developmental, and intellectual disabilities.
• Expertise in phone etiquette, empathetic messaging, and conflict resolution or de-escalation.
• Experience working with Thrio and Elation systems preferred.
• Strong organizational and detail-oriented skills with a self-starter, follow-through approach.
• Warm, engaging personality with the ability to connect with individuals virtually.
• Ability to work in a metric-driven and goal-oriented environment.

A key member of a growing mental health organization, the Senior Care Navigator leads proactive outreach to higher-risk clients and serves as a subject matter expert in care navigation tools and workstreams to improve operational efficiency. Collaborating across clinical staff and cross-functional stakeholders, this role supports clients from system entry through their first provider appointment and directly advances the organization's mission to deliver extraordinary care.

Functions

• Conduct proactive outreach to understand higher-risk clients' needs and take action with the support of clinical staff.
• Participate in initiatives and projects to identify, scope, and implement opportunities for increased efficiencies.
• Become a subject matter expert in tools and workstreams to iterate and improve them as the organization grows.
• Support clients along their care journey from entry into the system through their first provider appointment.
• Embody the organization's mission to deliver extraordinary care in every interaction with clients and colleagues.

Experience & Qualifications

• Bachelor's degree required; Master's level mental health degree preferred.
• 3-5 years of experience in Care Navigation or Coordination within mental health or healthcare.
• 1-3 years of experience supporting cross-functional initiatives with key stakeholders.
• Experience with telephonic crisis intervention.
• Understanding of the mental health industry to leverage insights for decision-making.
• Excellent verbal and written communication skills.
• Ability to adapt approach to multiple audiences.
• Detail-oriented with strong organizational skills.
• A self-starter mindset and openness to iterative processes.

Timely, organized care coordination across utilization management and case management depends on the Care Navigator, who handles initial follow-up calls for discharged patients, manages ER utilization reports, and supports referral and claims documentation. Based within a managed care environment and serving both clinical and administrative teams, this role enables accurate case tracking and appropriate resource connection for non-high-risk patients across the organization.

Accountabilities

• Coordinate patient care activities between Utilization Management and Case Management.
• Provide administrative support functions for Utilization Management and Case Management teams.
• Make initial follow-up calls to patients discharged from acute or post-acute facilities.
• Provide outreach and guidance to non-high-risk patients and assist them in obtaining community resources.
• Manage ER utilization reports and interventions to address inappropriate ER utilization.
• Assist the Medical Management team in gathering clinical information and supporting appropriate referrals and claims history.
• Complete accurate and timely documentation and develop spreadsheets and other tracking tools.

Technical Qualifications

• High School diploma required; Medical Assistant or nursing school education preferred.
• Experience in a managed care organization preferred.
• Knowledge of medical terminology required.
• Knowledge of vital signs and basic clinical skills.
• Familiarity with Electronic Medical Records.
• Proficiency with Microsoft Word, Excel, and internet-based tools.
• Excellent communication, problem-solving, organizational, and time management skills.
• Friendly, compassionate disposition with the ability to maintain patient confidentiality and work independently or as part of a team.

As the ED Care Navigator, this role coordinates patient transfers, facilitates pre-discharge follow-up appointments, and supports compliance with regulatory and accrediting standards to improve care quality within the Emergency Department. The emergency care team relies on this work to maintain patient flow, deliver staff and physician education on throughput processes, and ensure open communication between the Department Director and clinical operations.

Activities

• Assist with coordination of patient transfer needs.
• Facilitate follow-up appointments before patient discharge from the ED as necessary.
• Assist with clinical decisions when the Department Director or Unit Supervisor is unavailable.
• Collaborate with patient care providers to support compliance with regulatory, accrediting, and professional organization standards to improve care quality.
• Provide education to patients, staff, and physicians on patient flow and throughput processes.
• Support the Department Director and Administration by maintaining open communication, formulating recommendations on concerns, assisting with service recovery, and following the chain of command.

Position Requirements

• Graduate of an accredited nursing education program, BSN preferred.
• Current nursing licensure in applicable state.
• CCM certification from the Commission for Case Management or CPHQ certification from NAHQ (or obtained within 4 years).
• AHA BLS certification.
• AHA ACLS certification for the Emergency Department.
• AHA PALS certification.
• Minimum 3 years of clinical experience in acute care, including medical/surgical, perioperative, emergency, critical care, or obstetrical nursing.

Care Navigator delivers psychosocial interventions and case management services to an assigned patient panel through home visits, teleconferencing, and telephone, while maintaining communication across care teams, caregivers, and external health professionals. Success in the position means processing physician orders, developing comprehensive care plans, connecting patients to community resources, and sustaining accurate documentation with strict confidentiality across all encounters.

Operational Focus

• Collaborate with the care team to provide psychosocial interventions and case management services to a patient panel.
• Interact with patients in the home, via teleconference, or by telephone as appropriate.
• Maintain clear communication between care team members, patients, caregivers, and external health professionals.
• Assist with processing physician orders in the EMR, scheduling patient visits, and answering patient calls.
• Assist with development and implementation of comprehensive care plans for the patient panel.
• Develop knowledge of available community resources and assist patients in accessing them.
• Document all encounters accurately and on time, maintaining strict patient confidentiality.

Professional Experience

• At least 3 years of experience in health and/or social services.
• LPN or Medical Assistant certification preferred.
• Advanced customer service experience with strong oral and written communication skills.
• Comfortable interacting with patients and care teams both telephonically and in person.
• Self-motivated with the ability to follow defined operating procedures.
• Available for after-hours telephone support.
• Ability to travel to patient homes with reliable transportation and a good driving record.

The Care Navigator produces accurate member chart updates and care coordination support for Advanced Practice Clinicians serving members in skilled nursing and assisted living facilities, managing data entry, lab results, medication changes, and scheduling across an EMR platform. Working alongside APCs, facility staff, and member families, this role advances the quality and continuity of member care while enabling smooth transitions between facility, home health, and specialist settings.

Key Responsibilities

• Support APCs with overall coordination of member care, at the direction of the APC.
• Manage data entry and member chart updates, including new members, post-hospital visits, health maintenance, Stars measures, lab results, and medication entry.
• Obtain medical records, consult notes, hospital discharge summaries, and lab results following hospitalizations and physician appointments.
• Upload lab results, medication changes, and new member information into the EMR and assist with scheduling and transportation.
• Arrange facility and member education and build facility relationships.
• Support virtual family communication and clinical visits by operating an iPad during APC visits.
• Track skilled days, assist with DST completion, coordinate SNF transitions, and arrange Home Health and DME for applicable members.

Background & Experience

• High School Diploma or GED required.
• Certified Nursing Assistant or Certified Medical Assistant certification required.
• 3+ years of clinical or medical records experience with strong knowledge of medical terminology and EHR platforms.
• Experience with CMS compliance and medical team collaboration in cross-functional, multidisciplinary settings.
• Skilled in Microsoft Word, Excel, and Microsoft Office, including email, calendaring, and file management.
• Proficiency with EMR platforms.
• Excellent administrative, organizational, and communication skills.
• Ability to multitask and prioritize multiple deliverables.
• Access to reliable transportation for daily travel between nursing homes and assisted living communities.

Embedded within a care management department serving Medicaid and community-based populations, the Care Navigator develops member engagement through motivational interviewing, telephonic outreach, and coordination of wellness visits, referrals, and benefit resolution. Working closely with Care Managers, clinical staff, contracted vendors, and community-based providers, this role sustains accurate medical management documentation and improves administrative workflows that support member access to appropriate care.

Core Functions

• Use motivational interviewing skills to engage members in care management via telephonic outreach.
• Provide members with health information, resources, and information packets relevant to their identified conditions.
• Advocate for members by sharing information with community-based providers and following up on closed-loop referrals.
• Triage calls and cases to clinical staff, other departments, contracted vendors, and providers as appropriate.
• Manage referrals, perform telephonic screening assessments, and arrange wellness visits and preventative care reminders.
• Coordinate access to services, resolve benefit questions, and transfer members to the appropriate Care Manager as needed.
• Perform Care Management Case Closure Satisfaction Assessments and act as primary contact for Coordinated Transportation Solutions.
• Prepare department data and reports, provide administrative meeting support, and identify opportunities to improve administrative workflows.
• Maintain accurate and timely documentation in the medical management information system per contractual, policy, and accreditation requirements.

Minimum Qualifications

• Associate's degree in healthcare or a related field, or equivalent work experience.
• 2 years of office experience in a high-volume customer service, data entry, or healthcare administration environment.
• Prior experience working with Medicaid populations preferred.
• Knowledge of medical terminology strongly preferred.
• Proficiency with Microsoft Office products including Outlook, Word, and Excel.
• Strong motivational interviewing, oral, and written communication skills with the ability to engage members effectively.
• Strong organizational and time management skills with the ability to prioritize multiple tasks in a fast-paced environment.
• Bilingual proficiency preferred.

Reporting to departmental leadership, the Care Navigator refines access to care for diverse patient populations by processing referral authorizations, verifying insurance eligibility, and documenting encounters in compliance with regulatory and EMR requirements. Partnering with Patient Financial Services, managed care organizations, and community resource networks, this role reduces barriers to treatment and enables outpatient clinics to meet the care coordination and documentation standards required for quality service delivery.

Day-to-Day Responsibilities

• Monitor patients' progress via level of functioning, adherence to treatment plans, and recovery or relapse process.
• Schedule outpatient visits and follow-up appointments as needed.
• Provide education, counseling, and support to clients using culturally and linguistically appropriate strategies.
• Develop and maintain relationships with community resources to ensure patient access.
• Verify eligibility and benefits with insurance companies and communicate potential issues to patients.
• Process referral authorizations, submit to the appropriate managed care organization, and identify patients requiring prior authorization.
• Document patient encounters, interventions, and resource development efforts accurately in the EMR and comply with departmental and regulatory documentation requirements.
• Refer self-pay or insurance-issue patients to Patient Financial Services and communicate alternative payment options.
• Adapt to changing departmental needs, attend required training, and perform other administrative duties as assigned.

Knowledge, Skills & Abilities

• High School diploma required; Associate's or Bachelor's degree preferred.
• Experience working with families and patients from diverse backgrounds, including multicultural needs assessment and care planning.
• Knowledge of community, social, and health resources.
• Proficiency with Microsoft Office products including Word, Excel, and PowerPoint.
• Working knowledge of hospital registration systems and EMR platforms such as Epic.
• Strong verbal, written, and interpersonal communication skills.
• Good critical thinking, problem-solving, organizational skills, and flexibility in a fast-paced environment.
• Bilingual or multilingual skills appropriate to the patient population served preferred.