Geriatric Care Transitions Navigator

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

Benefits offered by this job

401(k) with company match

Health, Dental, Vision insurance

Health Savings Account

Life insurance

Paid Time Off

Travel reimbursement

Job summary

Community Physicians is seeking a Patient Care Navigator to act as a bridge between physicians, staff, patients, and families, ensuring smooth transitions of care across settings. You will build partnerships with families and community resources to provide patient- and family-centered support.

The role combines administrative medical support, transition management, and patient advocacy to promote high-quality care and reduce hospital readmissions.

Qualifications

• High school diploma or equivalent (Required).
• Graduate of an accredited Medical Assistant program is required.
• Certified Medical Assistant (CMA) is highly preferred.
• Current Basic Life Support (BLS) Certification.
• 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

• Coordinate transitions to the next level of care and schedule follow-up appointments.
• Create patient charts and enter demographics, medications, and diagnoses in the EMR.
• Assist with transition clinic services, patient intake, calls, and documentation.
• Conduct social risk factor assessments to identify unmet health or social needs.
• Identify high-risk patients who would benefit from transition services or remote monitoring, and assist enrollment.
• Attend IDT plan of care meetings and communicate daily with practitioners and Nurse Case Managers.
• Assist in collecting key quality metrics and program data.

Skills

Excellent bedside manner

Problem-solving abilities

Communication skills

Compassionate care

Education

High school diploma or equivalent

Graduate of accredited Medical Assistant program

Certified Medical Assistant (CMA) preferred

Tools

EMR/EHR experience

Job description

Community Physicians is seeking a Patient Care Navigator to act as a bridge between physicians, staff, patients, and families, ensuring smooth transitions of care across settings. You will build partnerships with families and community resources to provide patient- and family-centered support.

The role combines administrative medical support, transition management, and patient advocacy to promote high-quality care and reduce hospital readmissions.