Patient Care Navigator- ONSITE

Job description

At Community Physicians, we are 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 You Should Join Us? 1. Purpose-Driven Work: You will play a vital role in caring for medically complex older adults during their most vulnerable health transitions. Your expertise will directly impact patient outcomes, reduce hospital readmissions, and improve quality of life. 2. Collaborative and Supportive Environment: We believe in the power of partnership. You’ll work closely with facility staff, families, and interdisciplinary teams to ensure seamless, compassionate, and coordinated care. 3. Clinical Excellence and Innovation: We prioritize evidence-based practices and continuity of care, bringing clinical excellence to every bedside. Our model allows you to practice meaningful medicine while making a tangible difference in patients’ lives. 4. Professional Growth and Leadership: As part of our team, you’ll have opportunities to lead, innovate, and contribute to the growth of geriatric care in our community. We invest in our providers’ development and support their journey toward excellence. 5. A Culture of Compassion and Respect: We are committed to treating every patient with dignity, empathy, and respect—and we extend that same commitment to our team. Here, you’ll be part of a culture that values each member’s contribution and well-being. Job Overview The Patient Care Navigator serves as a vital bridge between our medical practitioners, facility staff, patients, and their families. This role is responsible for ensuring seamless patient transitions of care across health settings by developing effective partnerships with families, facility staff, and community resources. By combining administrative medical support, smooth transition management, and dedicated patient advocacy, the navigator promotes high-quality, relationship-based support that is patient- and family-centered. Compensation & Benefits Pay: $21.50-$30 per hour Job Type: Full-time Schedule: 8-hour shift, Monday to Friday Benefits Package 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 Key Responsibilities Transition & Family Support Collaborate with patients, families, and multidisciplinary medical professional team. Support patients and family members with transitions to the next level of care, including setting up follow-up appointments. Medical Assistant & Administrative Tasks 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. Assessments & Program Enrollment 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. Interdisciplinary Collaboration 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. Outreach & Quality Metrics Assist in the collection of key quality metrics and program performance improvement data. Qualifications & Requirements Education & Certification High school diploma or equivalent (Required). Graduate of an accredited Medical Assistant program is required. Certified Medical Assistant (CMA) is highly preferred. Experience Must meet at least one of the following criteria: High school diploma or equivalent is required. Certified Medical Assistant (CMA) from an accredited program is 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. Skills & Travel Requirements Ability to travel to several facility locations in the area. Excellent bedside manner, problem-solving abilities, and communication skills. Deep compassion for patient care, particularly when working with medically complex older adults.