[Hiring] Care Navigator @Greater Good Health

Role Description

• Conduct proactive outreach to schedule patient home, telehealth, and in-clinic visits to complete Annual Wellness Visits (AWVs), ensuring patients receive timely preventative care and individualized care plans.
• Accept inbound calls from patients to schedule AWVs and address care-related questions or concerns.
• Connect with the geriatric population to build trusting, long-term relationships — making patients feel calm, comfortable, and heard throughout their care experience.
• Identify and address barriers to engagement, including transportation, language, health literacy, financial hardship, and other social and environmental factors.
• Outreach to patients to complete key preventative screenings (colon cancer, mammograms, diabetic retina scans, HbA1c, and more), documenting outreach and establishing follow-through plans.
• Partner closely with assigned GGH Nurse Practitioners (NPs) to co-manage their patient panel, serving as the day-to-day coordination hub for scheduling, care follow-through, and patient communication.
• Build and optimize driving routes for GGH Nurse Practitioners completing home visits, maximizing time spent with patients.
• Coordinate patient cancellations, reschedules, and add-on visits with the NP to ensure continuity of care and efficient schedule management.
• Retrieve and reconcile medical records from outside providers, hospitals, health systems, and community organizations to ensure the care team has a complete and current view of each patient’s health history.
• Manage patients post-discharge from hospital or skilled nursing facility settings, coordinating timely follow-up visits and facilitating care plan transitions to reduce readmission risk.
• Follow up with patients on outstanding provider orders — including lab work, imaging, specialist referrals, and durable medical equipment — ensuring completion and routing results back to the care team.
• Coordinate referrals and activities for high-risk programs, facilitating smooth transitions between care settings and service providers.
• Support the care team in identifying and closing quality gaps, including HEDIS measures and chronic disease management needs.
• Handle protected health information (PHI) with discretion, adhering to HIPAA standards and GGH privacy policies at all times.
• Maintain timely, accurate, and thorough documentation of all patient interactions, outreach attempts, care coordination activities, and follow-up plans.
• Build strong, positive working relationships with GGH Nurse Practitioners and the Patient Outreach Team, and maintain professional communications with client partners and the broader care team.
• Participate in interdisciplinary care team meetings, contributing patient updates and coordinating action steps across team members.
• Maintain collaborative relationships with clinicians and the leadership team to support the development of new programs aimed at improving patient engagement, care coordination, and health outcomes.
• Complete other duties as assigned.

Qualifications

• 1–2 years of post-high school education or an associate’s degree; bachelor’s degree in health sciences, social work, public health, or a related field is a plus.
• 1–3 years of experience working in standard operating systems (Windows, MS Word, MS Excel, Internet, and other applicable software).
• 1–3 years of experience in a patient-facing healthcare role.
• Excellent verbal and written communication skills, including the ability to communicate complex health information in an accessible and empathetic way.
• Outstanding phone skills with sensitivity toward protected health information (PHI) and HIPAA compliance.
• Familiarity with medical terminology and basic understanding of chronic disease management in older adults.
• Must be organized, detail-oriented, and able to multitask in a fast-paced care coordination environment.
• Must be adaptable, a team player, and comfortable working both independently and collaboratively.
• Professionalism in appearance, communication, and demeanor.
• Solid critical thinking and problem-solving skills with the ability to manage complex, multi-step patient situations.

Requirements

• Healthcare experience in a patient-facing or care coordination role (Strongly Preferred).
• Experience with or training in motivational interviewing, health coaching, or behavioral change techniques.
• Experience retrieving medical records from hospitals, EHR systems, or external providers.
• Familiarity with post-discharge care workflows, transitions of care, or case management principles.
• Experience with value-based care models, population health management, or Medicare Advantage programs.
• 1+ years of experience working with Medicare or senior/geriatric populations.
• Experience with HEDIS gap closure or quality improvement initiatives.
• 1+ years of call center experience and managing phone queues.
• Basic Excel skills: navigation, data entry, filtering, and sorting.
• Knowledge of or experience with EHR/EMR platforms.
• Certification in care coordination, patient navigation, or a related area (e.g., CCM, ACM, CPHQ) is a plus.
• Strong preference for bilingual candidates (English/Spanish).

Physical Demands

• 8 hours per day seated at a home-office desk, working in front of a computer using a keyboard.
• Two 10-minute breaks throughout the day, as well as a one-hour meal break.

Benefits

• Competitive Compensation Package: We offer a competitive compensation package.
• Comprehensive Medical, Dental, and Vision Benefits: Take advantage of comprehensive healthcare coverage, including medical, dental, and vision benefits, to prioritize your health and well-being. Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs) available.
• Paid Time Off and Parental Leave: Enjoy paid holidays, vacation time, and paid parental leave to maintain a healthy work-life balance and spend quality time with your loved ones.
• 401K Program with Company Match: Plan for your future with our 401K program, featuring a company match, to help you save for retirement.
• Wellness Resources: Access to BetterHelp sessions and a monthly wellness benefit to support your physical, mental, and emotional well-being.
• Comprehensive Life and AD&D Coverage: Enjoy peace of mind with 100% premiums covered by GGH for Basic Life and Accidental Death & Dismemberment (AD&D) insurance for full-time team members. Additionally, voluntary supplemental life insurance is offered at a discounted rate.
• Employee discount savings program: Save on travel, entertainment, streaming services, online shopping and so much more!
• Voluntary Insurance plans: We offer voluntary short term disability, critical illness and accident plans for additional financial security during periods of illness or injury that prevent you from working for a set period of time.