Care Coordination & Navigation Specialist (CCNS)

About the Role

We're looking for an experienced Care Navigator or Care Coordinator to join our virtual program serving patients in Pennsylvania, New Jersey, New York, and Delaware (with more to come!). This role combines direct patient engagement with substantive case management — you'll be a first point of contact for patients reaching out with a need, and you'll also carry your own caseload, building individualized care plans and seeing needs through to resolution.

Most patients come to us with more than one open need at a time, and the barriers they face are specific: a particular insurance rule, a program with a waitlist, a resource that exists in one county and not another. You'll move fluidly between fast-turnaround patient support — scheduling, triage, troubleshooting — and the slower, more deliberate work of researching resources and following a case to confirmed resolution.

The care navigation program at Ophelia currently primarily serves patients in our Centers of Excellence (CoE) in Pennsylvania, and navigation happens virtually — mostly over SMS, with phone, EMR messaging, and Zoom as needed. You'll work closely with a clinical team who are active in the same patient records, and you'll document your work as you go so the whole team stays informed.

This is a good fit for someone who is comfortable building trust with patients through consistent, purposeful contact over time, moves easily between high-volume triage and focused casework, and understands that in a virtual care setting, good documentation is part of good care.

This role reports to the Manager of Care Navigation.

What You'll Do

Patient Engagement & Triage

• Serve as a first point of contact for inbound patient communication, quickly assessing urgency and either resolving the request or triaging it to the appropriate team member
• Support scheduling of visits with the clinical team, help improve visit attendance, and coordinate UDS logistics
• Maintain and update patient data accurately across systems
• Troubleshoot technology issues patients encounter with our platforms
• Practice active listening, empathy, and solution-focused approaches — providing emotional support, de-escalation, and education as needed

Care Navigation & Case Management

• Manage an active caseload of patients, developing and maintaining individualized care plans
• Reach patients by SMS and phone to assess needs, clarify barriers, and keep cases moving — building rapport through consistency rather than long sessions
• Research targeted resources for each patient based on their specific situation — insurance status, location, income, and the actual barrier they're facing
• Follow cases through to confirmed resolution
• Escalate the most complex cases for specialist support, and facilitate step-down back to your caseload when appropriate

Resource Coordination

• Maintain current knowledge of resources, programs, and eligibility rules across PA, NJ, NY, and DE
• Navigate public benefit systems including Medicaid, SNAP, transportation assistance, housing programs, and behavioral health services
• Build relationships with community-based organizations and providers in the region
• Provide warm handoffs, direct scheduling, or guided next steps based on what each patient needs

Documentation & Collaboration

• Document your work in the EMR as you go — activity, resource decisions, status changes, and next steps — so the clinical team always has the full picture
• Collaborate with providers through shared patient records, escalating clinical concerns, safety issues, and urgent needs to the appropriate clinical team member promptly and with the right context
• Follow established processes and protocols to ensure patients receive consistent, high-quality care
• Participate in team meetings and case reviews

Qualifications

Required

• 2+ years in care navigation, case management, community health, or patient-facing customer support in a healthcare setting — with meaningful experience delivered virtually or over the phone
• Experience with SDOH navigation (housing, transportation, food access, behavioral health, benefits enrollment) or experience delivering outstanding patient experience in a high-volume, multi-channel environment (ideally with a ticketing system) — we're looking for strength in at least one, with willingness to grow into both
• Working knowledge of, or ability to quickly learn, community resources, programs, and systems in PA, NJ, NY, and/or DE
• Proficient and comfortable using EMR, ticketing systems, or care management platforms as primary daily tools, with strong overall tech savviness
• Strong written communication skills — clear and professional with patients over text, phone, and other channels
• Ability to independently manage a caseload, prioritize across multiple channels (SMS, EMR, phone, Slack) and competing needs, and track work through to resolution
• Strong organizational skills and a keen eye for detail, including accuracy in patient records
• High school diploma or GED required; associate's or bachelor's in social work, public health, or human services strongly preferred
• Demonstrated ability to work with diverse patient populations with cultural humility — adapting communication and approach to each patient's background, values, and circumstances
• A bias for action: proactively taking on work without prompting, and adapting well to a fast-changing environment

Strongly Preferred

• Experience in a Center of Excellence or specialty care program serving patients with complex, co-occurring needs
• Familiarity with Medicaid populations and managed care requirements in NJ or PA
• Experience navigating drug & alcohol, psychiatric care, or specialty behavioral health resources
• Familiarity with trauma-informed care, harm reduction philosophy, and motivational interviewing as frameworks that shape how you listen, communicate, and engage

Who Thrives in This Role

Our strongest people in this role get real satisfaction from both sides of the work: the fast-paced problem-solving of triage and patient support, and the longer-arc work of holding a caseload in mind and moving it forward over weeks. They build genuine relationships with patients over SMS and phone, and they understand that in a virtual setting, how you document your work is how care continues when you're not there. They meet patients where they are — providing judgment-free support, honoring individual recovery paths, and respecting each person's timeline for progress.

This role is a strong fit if you thrive in a structured environment with clear accountability, enjoy variety in your day-to-day work, and find meaning in both connecting patients to immediate support and solving the harder, longer-term problem underneath. It may not be the right fit if you're looking for a narrowly-scoped role, long open-ended patient sessions, or in-person community presence. This position is fully remote and SMS-first.

Work Environment

• Fully remote — reliable internet and a private workspace required
• All patient contact via SMS, phone, EMR, and Zoom — no in-person visits
• EMR- and ticketing-based workflow; comfort with digital tools is essential
• Collaborative team across PA and NJ with regular virtual team touchpoints
• Schedule: This role is available on two schedules — Tuesday–Saturday or Sunday–Thursday (we are hiring one person for each). Standard business hours apply; specify shift start/end times when posting.

Our Benefits Include:

• Competitive medical, vision, and health insurance (many plans are fully covered for the employee!)
• Start with 20 days (4 weeks) of PTO, increasing to 5 weeks after 2 years and 6 weeks after 5 years of tenure
• 10 company holidays
• Work From Home Stipend
• 401k Contribution Platform
• Additional benefits offered through our benefits provider such as life insurance, short and long term disability, financial wellness, virtual primary care, among others!

#LI-Remote

Interested in learning more about Ophelia and this role? Apply to work with us!