Geriatric Care Transition Navigator

Community Physicians; Deerfield (IL); On-site; USD 29,618 - 41,328; Full time

Benefits offered by this job

401(k) with company matching

Health Insurance

Dental Insurance

Vision Insurance

Health Savings Account (HSA)

Life Insurance

Paid Time Off (PTO)

Travel reimbursement

Job summary

Community Physicians seeks a Patient Care Navigator to bridge care across settings for older adults in skilled nursing and post-acute care. You will coordinate transitions, support families, and maintain patient-centered documentation in the EMR system.

The role emphasizes collaboration with multidisciplinary teams, timely follow-ups, and proactive involvement in quality improvement and care coordination.

Qualifications

• High school diploma or equivalent required.
• Graduate of an accredited Medical Assistant program is required.
• Certified Medical Assistant (CMA) is highly preferred.
• Minimum of 1 to 3 years of proven experience with EMR/EHR systems and taking vital signs.
• 5–7 years of experience in Skilled Nursing Facilities.
• Strong knowledge of medical terminology.

Responsibilities

• Collaborate with patients, families, and multidisciplinary medical professional team.
• Support patients and family members with transitions to the next level of care, including setting up follow-up appointments.
• Perform chart creation and data entry of patient demographics, medications, and diagnoses within the EMR system.
• Assist with transition clinic services, patient intake, phone calls, and documentation.
• Conduct patient social risk factor assessments to identify unmet health or social needs.
• Identify high-risk, complex patients who would benefit from transition services, chronic disease management, or remote monitoring, and assist them with enrollment.
• Serve as a reliable point of contact and advocate for the patient.
• Attend IDT (Interdisciplinary Team) plan of care meetings at facilities and communicate daily with practitioners and Nurse Case Managers.
• Assist in the collection of key quality metrics and program performance improvement data.

Skills

Bedside manner

Communication skills

Problem solving

Compassion

Education

High school diploma or equivalent

CMA program graduate

CMA certification

Tools

EMR/EHR systems

Job description

Community Physicians seeks a Patient Care Navigator to bridge care across settings for older adults in skilled nursing and post-acute care. You will coordinate transitions, support families, and maintain patient-centered documentation in the EMR system.

The role emphasizes collaboration with multidisciplinary teams, timely follow-ups, and proactive involvement in quality improvement and care coordination.