Care Navigator - Mountain Time - MST

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Position:Care Navigator
- Mountain Time
- Applicants MUST be comfortable working 7a-4p MST

Location: Remote

Remote Status: Remote

Job :672

# of Openings:1

Job Title: Care Navigator
Job Location: Remote - Mountain time zone - patients located in Mountain time
Applicants must be comfortable working 7a-4p MST

• 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.
• Other duties as assigned.

• Completing 50–100 outbound calls per day.
• Achieving conversion rate expectations for AWV scheduling and preventative care outreach.
• Successfully managing post‑discharge follow‑up to minimize care gaps and reduce avoidable readmissions.
• Timely retrieval and reconciliation of outside medical records to support…