Care Navigator

Monogram Health; Tyler (TX); On-site; USD 57,000 - 73,000; Full time

Benefits offered by this job

Medical, dental, and vision insurance

401k with employer match

PTO - 20 days

Paid holidays and parental leave

Job summary

Monogram Health is seeking a Care Navigator to identify and resolve social determinants of health needs for an assigned pod panel. This role focuses on non-clinical barriers such as housing, food insecurity, transportation, utilities, and caregiver support, coordinating with the care team to ensure timely resolution.

The Care Navigator conducts proactive outreach, documents needs and outcomes, and guides patients through enrollment processes with community resources, ensuring consistent

Qualifications

• High school diploma or GED; bachelor’s degree preferred.
• Minimum 2 years in care coordination or related field.
• Bilingual skills preferred.

Responsibilities

• Identify unmet social needs using CMS-aligned SDoH assessment via proactive outreach.
• Engage patients to understand priorities, build rapport, and serve as a non-clinical support lead.
• Document SDoH needs across housing, food, transportation, utilities, finances, and caregiver support.
• Connect patients to community resources and assist with referrals and enrollment.
• Follow up to confirm resource use and full resolution of barriers.
• Escalate clinical or safety concerns through pod channels when needed.
• Log all interactions and outcomes in Pt. 360 per standards.

Skills

Communication

Relationship building

Multitasking

Diversity awareness

Education

High school diploma or GED

Bachelor's degree preferred

Job description

Care Navigator

Position: Care Navigator

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, and 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 – every step of the process remains with the Care Navigator until the need is fully resolved.
• 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 – partial resolution or pending status must remain active and tracked.
• Drive timely closure of all open SDoH cases within established timeframes and elevate stalled cases according to defined workflows.
• Partner closely with pod clinicians including RNs, APPs, and BHCs to align on patient SDoH needs and ensure the care team has full visibility into social barriers affecting patient engagement.
• 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.
• Monitoring ongoing SDoH needs until resolution, ensuring timely and accurate closure.
• Support internal quality improvement initiatives and data collection efforts related to broader SDoH outcomes.

Position Requirements

• 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.

Compensation

The base salary range for this role is $57,165 to $73,130 and reflects the range of experience and qualifications we may consider. Final compensation will be determined based on geographic location and job-related factors such as experience, skills, education, certifications, and internal compensation considerations. While a larger range is posted, most offers will typically fall within a narrower band based on these factors.

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

About Monogram Health

Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders. Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home. Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum.