Field-Based Care Transition Navigator

Sierra Home Health and Hospice; Las Cruces (NM); On-site; USD 42,000 - 58,000; Full time

Job summary

Sierra Home Health and Hospice is seeking a Patient Navigator to support medically and socially complex patients through safe, coordinated transitions from hospital to home and community.

You will provide ongoing care management during the episode of care, coordinating with hospital discharge planners, social workers, and clinical teams to ensure seamless care plans and optimal outcomes.

Qualifications

• Associate or bachelor’s degree in a relevant field is preferred.
• Minimum 2 years in healthcare, care coordination, social services, or related field preferred.
• Bilingual English/Spanish strongly preferred; diverse communities served.
• Experience with hospital discharge planning or care transitions a plus.
• Knowledge of social determinants of health and community resource navigation.
• Valid driver’s license and ability to travel locally.

Responsibilities

• Identify patients discharged from hospital who need home health or hospice support.
• Coordinate with discharge planners, case managers, and social workers for safe transitions.
• Post-discharge follow-up with patients and families to address barriers and resources.
• Collaborate with clinical teams to ensure continuity of care plans and patient goals.
• Assess social determinants of health and connect patients with community resources.
• Maintain accurate documentation of patient interactions and referrals in systems.
• Build relationships with hospital partners and community organizations for referrals.

Skills

Bilingual English/Spanish

Interpersonal communication

Care coordination

Discharge planning knowledge

HIPAA privacy knowledge

Education

Associate's or Bachelor's degree in social work, healthcare administration, nursing, public health

Tools

Electronic health records (EHR)

Job description

Sierra Home Health and Hospice is seeking a Patient Navigator to support medically and socially complex patients through safe, coordinated transitions from hospital to home and community.

You will provide ongoing care management during the episode of care, coordinating with hospital discharge planners, social workers, and clinical teams to ensure seamless care plans and optimal outcomes.