Patient Health Navigator for Maternal Health Program

Agape-Community-Health-Center; Jacksonville (FL); On-site; USD 42,000 - 65,000; Full time

Job summary

Agape Family Health in Jacksonville, FL is seeking a Patient Health Navigator for the Maternal Health Program. You will guide pregnant patients—especially those with high-risk conditions—into timely prenatal, obstetric, and postpartum care.

You will act as a consistent contact, reducing barriers and connecting patients to Medicaid resources, ensuring high-risk patients receive timely care in the high-risk OB clinic.

Qualifications

• High school diploma or equivalent required; associate's degree preferred.
• CHW certification preferred; willing to pursue certification if not yet certified.
• Current CMA/RMA or MA training/experience for back-up clinical support.
• Experience in community health, care coordination, patient navigation, or clinical support.
• Familiarity with Medicaid eligibility, PRAPARE, and community resource referral.
• Proficiency with ATHENAOne and strong documentation skills.
• Bilingual English/Spanish strongly preferred.

Responsibilities

• Outreach, verify insurance eligibility, and enroll patients in Medicaid, sliding-fee, or patient-assistance programs.
• Connect patients to community resources addressing barriers to care (transportation, housing, food).
• Educate patients about the Maternal Health Program and local initiatives.

Skills

CHW Certification

CMA/RMA

Bilingual EN/ES

EHR Proficiency

Care Coordination

Documentation

Education

High school diploma or equivalent

Associate's degree preferred

Tools

athenaOne

Job description

Patient Health Navigator — Maternal Health Program

Department: Women's Health / Maternal Health Program

Reports To: Women's Health Coordinator / Maternal Health Program Director

Status: Full-Time | Non-Exempt

Location: Agape Family Health — Jacksonville, Duval County, FL

Position Summary

The Patient Health Navigator supports the Agape Community Maternal Care Program by guiding pregnant patients — particularly those with moderate- to high-risk conditions — into timely, coordinated prenatal, obstetric, and postpartum care. The Navigator serves as a consistent point of contact who reduces barriers to care, connects patients to community and Medicaid resources, and helps ensure patients meeting high-risk criteria are seen promptly in Agape's high-risk obstetric clinic. The Navigator plays a direct role in helping Agape meet the milestones and quality measures established under its Community Maternal Care Program agreements with partner hospital systems, and provides back-up clinical support as a Medical Assistant when program needs require.

Key Responsibilities

• Conduct patient outreach, verify insurance eligibility prior to scheduling, and enroll patients in Medicaid, sliding-fee, or patient-assistance programs.
• Connect patients facing barriers to care — including social drivers of health such as transportation, housing, and food insecurity — with community resources, medical devices, and Medicaid benefits.
• Serve as a friendly, consistent presence in the community, engaging patients and providing education about the Maternal Health Program and related local initiatives.

High-Risk OB Clinic Navigation

• Apply a standardized clinical risk-screening protocol to identify pregnant patients meeting moderate- to high-risk criteria (e.g., hypertension, gestational diabetes, preeclampsia, behavioral health needs).
• Ensure patients meeting high-risk criteria are promptly referred to and scheduled with the Agape obstetrician, using dedicated obstetrical appointment slots reserved for the target patient population.
• Coordinate warm handoffs between Agape prenatal/primary care and partner hospital systems' obstetrical and delivery services, including direct scheduling and EHR referral flags.
• Support postpartum care coordination, including scheduling comprehensive postpartum visits and helping arrange visits prior to hospital discharge.

Supporting Partner Hospital System Agreement Metrics

• Help Agape meet the quality measures and program milestones established under its Community Maternal Care Program agreements with partner hospital systems, including timely obstetric access for referred high-risk patients, timely entry into prenatal care, and completion of postpartum care.
• Track and document referral timelines, appointment adherence, and patient outcomes to support quarterly performance reporting and Joint Committee review.
• Maintain accurate records that enable Agape to demonstrate good-faith progression toward program milestones each quarter.

Scheduling & Documentation

• Manage patient charts, coordinate virtual telehealth consultations, schedule on-site clinic visits, and complete enrollment forms.
• Handle electronic health record (athenaOne) onboarding and maintain complete, accurate documentation in accordance with HIPAA and program requirements.

Back-Up Clinical Support (Medical Assistant)

• When program needs require, provide back-up clinical support in the Medical Assistant capacity — including patient intake, vital signs, specimen collection, rooming, and clinical documentation — to maintain continuity of care in the high-risk OB clinic.
• Assist clinical providers during patient visits as directed, consistent with Medical Assistant scope and Agape protocols.

Qualifications

• High school diploma or equivalent required; associate's degree preferred.
• Community Health Worker (CHW): Current Florida Certification Board CHW certification preferred. Candidates who are not yet certified must be willing to participate in and complete a CHW training and certification program, the cost of which will be sponsored and paid for by Agape Family Health.
• Current Medical Assistant certification (CMA/RMA) or documented MA training/experience required to provide back-up clinical support.
• Experience in community health, care coordination, patient navigation, or a clinical support role, preferably in an FQHC or maternal health setting.
• Familiarity with Medicaid eligibility, social-needs screening (e.g., PRAPARE), and community resource referral.
• Proficiency with electronic health records (athenaOne preferred) and strong documentation skills.
• Bilingual (English/Spanish) strongly preferred, given the population served.
• Strong interpersonal skills, cultural competence, and a patient-centered, compassionate approach.
• Ability to manage a caseload, prioritize high-risk patients, and meet time-sensitive referral and follow-up targets.
• Comfort working across clinical and community settings and collaborating with multidisciplinary teams.
• Attention to detail in tracking metrics and maintaining audit-ready documentation.
• Discretion in handling confidential patient information in compliance with HIPAA.