Chronic Care Patient Navigator

Living Water Clinic; Lindsay (CA); On-site; USD 30,000 - 47,000; Full time

Benefits offered by this job

Health insurance

401(k) matching

Paid time off

Job summary

Living Water Clinic – Clinica Agua Viva in Lindsay, CA is seeking a Chronic Care Patient Navigator to engage patients, coordinate enrollment, and support device-based remote monitoring. You will schedule visits, track readings, and liaise with clinical staff to ensure timely follow-up and patient education.

The role emphasizes effective communication, organization, and the ability to work across care teams while maintaining patient confidentiality in a HIPAA-compliant environment.

Qualifications

• High school diploma or equivalent required.
• Experience in patient scheduling, medical office support, patient navigation, or care coordination preferred.
• Medical assistant, community health worker, or related training preferred.
• Strong communication, organization, customer service, and follow-through skills.
• Comfortable using electronic health records, spreadsheets, and remote monitoring technology.
• Ability to protect patient confidentiality and follow HIPAA requirements.

Responsibilities

• Outreach and engage patients for chronic care services and enrollment.
• Explain program participation and next steps using approved materials.
• Make follow-up calls for missed appointments or data readings.
• Schedule initial visits, RPM reviews, and device education visits.
• Coordinate with APEX and LWC teams for appointments and escalations.
• Document patient contacts and scheduling actions in designated systems.
• Provide coverage across LWC locations as assigned.

Skills

Patient navigation

EHR systems

Scheduling

Communication

confidentiality

Education

High School Diploma

Job description

Job Title: Chronic Care Patient Navigator
Company: Living Water Clinic – Clinica Agua Viva
Location: Lindsay, California

Essential Duties and Responsibilities:

• Patient Outreach and Engagement
• Contact patients to introduce chronic care services and coordinate enrollment according to approved workflows.
• Explain program participation, expectations, and next steps using approved materials.
• Make follow-up calls to patients who miss appointments, need assistance, or are not submitting device readings.
• Identify barriers such as language, transportation, technology, or difficulty reaching the care team and connect patients with appropriate support.
• Communicate respectfully and provide services in the patient’s preferred language when qualified.
• Scheduling and Follow-Up
• Schedule initial visits, quarterly RPM reviews, follow-up appointments, and device education visits.
• Coordinate appointments with APEX providers and LWC clinic teams.
• Provide appointment reminders, reschedule missed visits, and track outstanding follow-up needs.
• Coordinate warm transfers according to established workflows.
• Assist with distributing and setting up blood pressure monitors, glucose meters, scales, and pulse oximeters.
• Teach patients how to use and care for devices using approved instructions and teach-back.
• Help troubleshoot basic device, connectivity, and reading-transmission issues; refer unresolved problems to APEX technical support.
• Coordinate replacement devices, supplies, returns, and retrieval of unused equipment.
• Maintain accurate device assignment and inventory records.
• Promptly route reported symptoms, abnormal readings, and clinical questions to licensed clinical staff according to established escalation procedures.
• APEX and LWC Coordination
• Serve as a daily operational liaison between APEX and LWC.
• Communicate scheduling needs, patient concerns, device issues, enrollment updates, and unresolved follow-up items.
• Track issues through resolution and elevate delays to the Care Management Lead.
• Help maintain accurate clinic, provider, and patient assignments across approved systems.
• Participate in vendor meetings and communicate assigned action items to the appropriate teams.
• Documentation and Reporting
• Document patient contacts, outreach attempts, education, scheduling actions, device assistance, and follow-up needs in designated systems.
• Maintain work queues, outreach logs, device trackers, and issue trackers.
• Assist with reports on enrollment, patient engagement, completed visits, missed appointments, and device use.
• Flag possible duplicate program enrollment, insurance changes, and enrollment discrepancies for review.
• Follow approved processes for patient consent, enrollment, and disenrollment; route eligibility and billing questions to designated staff.
• Team Support and Additional Duties
• Coordinate with providers, medical assistants, scheduling, billing, ECM, and CHW teams to support consistent patient follow-up.
• Assist with preparing patient education materials and organizing program supplies.
• Participate in training, workflow updates, quality improvement activities, and team meetings.
• Provide coverage across LWC locations as assigned.
• Perform other related duties as assigned.

Requirements:

• High school diploma or equivalent required.
• Experience in patient scheduling, medical office support, patient navigation, or care coordination preferred.
• Medical assistant, community health worker, or related training preferred.
• Strong communication, organization, customer service, and follow-through skills.
• Comfortable using electronic health records, spreadsheets, and remote monitoring technology.
• Ability to protect patient confidentiality and follow HIPAA requirements.
• Scope of Role
• This is a patient support and coordination position. Clinical assessment, interpretation of readings, medication advice, and treatment decisions must be referred to licensed clinical staff.

Performance Expectations:

• Timely patient outreach, scheduling, and follow-up.
• Reliable tracking and resolution of device and vendor issues.
• Prompt escalation of clinical concerns.
• Respectful patient service and effective teamwork.

Personal Qualities:

• Customer-focused with a commitment to providing excellent service.
• Team player who can also work independently.
• Adaptable and flexible to meet changing patient and provider needs.
• Empathetic and patient-centered in resolving scheduling inquiries.
• Demonstrates professionalism, integrity, and strong ethical conduct.

Key Skills:

• Exceptional organizational and multitasking abilities.
• Clear, compassionate communication with patients and healthcare professionals.
• Proficiency with scheduling and EHR systems.
• Accuracy in maintaining calendars and patient information.
• Ability to manage multiple priorities efficiently.
• Working knowledge of medical terminology and healthcare workflows.

Physical Requirements:

• Ability to sit for extended periods and use a computer regularly.
• Clear verbal communication and good hearing for phone and in-person interactions.

We Offer:

• Health, dental, and vision insurance
• 401(k) matching
• Paid time off
• Opportunity to join a growing healthcare organization and gain valuable experience in a mission-driven clinical setting

About Us:

Living Water Clinic – Clinica Agua Viva is dedicated to providing compassionate, comprehensive healthcare to our community. We believe in treating every patient with dignity and care, guided by faith and service.

Living Water Clinic – Clinica Agua Viva is an equal opportunity employer committed to diversity, equity, and inclusion. We welcome all qualified individuals to apply and become part of our mission to deliver efficient, patient-centered healthcare.