Care Transitions Navigator

Sierra Health Care Inc.; Las Cruces, Northern (NM, KY); Hybrid; USD 42,000 - 60,000; Full time

Job summary

Sierra Health Care Inc. in Las Cruces, NM seeks a Patient Navigator to support medically and socially complex patients through transitions from hospital to home and community. This role includes ongoing care management throughout the episode of care.

You will coordinate with hospital discharge planners, case managers, and social workers to ensure safe, timely transitions and advocate for patients across the care continuum.

Qualifications

• Minimum 2 years in healthcare, care coordination, or related fields.
• Experience with care transitions and discharge planning preferred.
• Experience with medically and socially complex patients is desirable.
• Familiarity with electronic health records and care management tools.

Responsibilities

• Identify patients discharged needing home health or hospice transitional support.
• Coordinate with discharge planners, case managers, and social workers.
• Follow up post-discharge to assess transition success and barriers.
• Collaborate with clinical teams to align patient goals across care continuum.
• Assess social determinants of health and connect to community resources.
• Maintain documentation of interactions, referrals, and outcomes.
• Represent patient needs in interdisciplinary conferences and meetings.
• Track outcomes and participate in quality improvement efforts.
• Educate patients and families on available services and access.
• Travel locally and work independently in the field as required.

Skills

Bilingual English/Spanish

Interpersonal skills

Independent field work

Computer literacy

Education

Degree in social work

Healthcare administration or public health

Job description

Sierra Health Care Inc. in Las Cruces, NM seeks a Patient Navigator to support medically and socially complex patients through transitions from hospital to home and community. This role includes ongoing care management throughout the episode of care.

You will coordinate with hospital discharge planners, case managers, and social workers to ensure safe, timely transitions and advocate for patients across the care continuum.