[Hiring] Care Navigator @Monogram Health

Role Description

The Care Navigator is a patient-facing professional responsible for end-to-end identification, navigation, and resolution of social determinants of health (SDoH) needs for an assigned pod panel. This role serves as a dedicated SDoH resource, conducting proactive outreach, connecting patients to community resources, following through to confirmed resolution, and documenting closure in accordance with established standards.

Operating as an integrated member of the pod care team, the Care Navigator addresses non-clinical barriers including:

• Housing instability
• Food insecurity
• Transportation challenges
• Utility needs
• Financial strain
• Caregiver support

The Care Navigator follows defined SDoH workflows and escalation pathways and does not deliver clinical, therapeutic, or medical services.

Responsibilities

• Conduct proactive outreach to patients to identify unmet social needs using the nine-domain CMS-aligned SDoH assessment.
• Engage patients in goal-oriented conversations to identify priorities, assess readiness, and build rapport as a consistent and reliable point of contact for non-clinical support needs.
• Identify and document SDoH needs across all nine domains including housing, food, transportation, utilities, financial strain, social isolation, and caregiver support.
• Research and connect patients to community-based resources, local programs, public benefits, and referral partners appropriate to their identified SDoH needs.
• Guide patients through application, referral, and enrollment processes to ensure successful program connection.
• Perform timely follow up to verify resource utilization, confirm access, and ensure complete resolution of social barriers.
• Own each SDoH case from initial identification through confirmed closure.
• Document all interventions, follow-up contacts, and resolution outcomes accurately in Pt. 360 at each stage of the process.
• Ensure no SDoH case is considered closed until resolution is confirmed and documented.
• Drive timely closure of all open SDoH cases within established timeframes and escalate stalled cases according to defined workflows.
• Partner closely with pod clinicians including RNs, APPs, and BHCs to align on patient SDoH needs.
• Escalate clinical, behavioral health, safety, or high-risk psychosocial concerns immediately through established pod communication channels.
• Participate in interdisciplinary huddles and complex case discussions to contribute SDoH insights and coordinate resolution across the care team.
• Log all patient interactions, identified needs, interventions, and resolution outcomes accurately within Pt. 360 in accordance with documentation standards.
• Monitor ongoing SDoH needs until resolution, ensuring timely and accurate closure.
• Support internal quality improvement initiatives and data collection efforts related to broader SDoH outcomes.

Qualifications

• High school diploma or GED; Bachelor’s degree in public health, human services, social sciences, or related fields is preferred.
• Minimum of (2) years of experience in care coordination, patient navigation, community health, or social services support.
• Demonstrated communication and relationship building skills.
• Comfort working with diverse populations and complex social needs.
• Ability to manage multiple priorities in a fast-paced environment.
• Experience working with Medicaid, Medicare, or value-based care populations is preferred.
• Familiarity with community resources and benefit programs is preferred.
• Bilingual language skills are preferred.

Benefits

• Comprehensive Benefits: Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts.
• Financial & Retirement Support: Competitive compensation, 401k with employer match, and financial wellness resources.
• Time Off & Leave: 20 PTO days, 7 paid holidays, and 1 floating day to make your own, and paid parental leave.
• Wellness & Growth: Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts.