Patient Health Navigator for Maternal Health Program

Agape Community Health Center; Jacksonville (FL); On-site; USD 42,000 - 64,000; Full time

Job summary

Agape Community Health Center seeks a Patient Health Navigator to guide pregnant patients through prenatal and postpartum care, focusing on high-risk cases and Medicaid enrollment. The role connects families to social support and medical resources while supporting a high-risk OB clinic and care coordination across hospital systems.

Responsibilities include scheduling, outreach, and ensuring timely care transitions.

Qualifications

• High school diploma or equivalent; associate's degree preferred.
• CHW certification preferred; candidates not certified must complete sponsored CHW training/certification.
• CMA/RMA certification or MA training/experience required for back-up clinical support.
• Experience in community health, care coordination, patient navigation, or clinical support, preferably in an FQHC or maternal health setting.
• Familiarity with Medicaid eligibility, PRAPARE, and community resource referral.
• Proficiency with electronic health records (athenaOne preferred) and strong documentation skills.
• Bilingual (English/Spanish) strongly preferred.
• Strong interpersonal skills, cultural competence, and patient-centered approach.
• Ability to manage a caseload 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.

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 with community resources, medical devices, and Medicaid benefits.
• Engage patients and educate them about the Maternal Health Program and local initiatives.

Skills

Care coordination

Patient navigation

Community health

Medicaid knowledge

PRAPARE

Resource referral

athenaOne

Documentation

Bilingual English/Spanish

Interpersonal skills

Cultural competence

Patient-centered care

Caseload management

Time management

HIPAA compliance

Discretion with confidential data

Team collaboration

Attention to detail

Education

High school diploma or equivalent

Associate's degree preferred

Florida CHW certification preferred

CMA/RMA certification or MA training/experience

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.