Patient Navigator

Sierra Home Health & Hospice; Las Cruces (NM); On-site; USD 42,000 - 64,000; Full time

Job summary

Sierra Home Health & Hospice is seeking a Patient Navigator to support medically and socially complex patients through safe transitions from hospital to home and community. You will provide ongoing care management during the care episode and collaborate with hospital discharge planners and care teams.

Ideal candidates are bilingual in English and Spanish, with 2+ years in healthcare or case management, and familiarity with social determinants of health.

Qualifications

• Associate's or bachelor's degree in social work, healthcare administration, nursing, public health, or related field.
• Minimum 2 years in healthcare, care coordination, case management, or social services.
• Experience with medically and socially complex patient populations.
• Spanish-English bilingual strongly preferred.
• Knowledge of social determinants of health and community resources.

Responsibilities

• Identify suitable home health or hospice patients at discharge for transitional support.
• Coordinate with hospital discharge planners and social workers for safe transitions.
• Conduct post-discharge follow-up to assess transition success and barriers.
• Collaborate with clinical teams to align care plans.
• Document patient interactions and outcomes in systems.
• Build relationships with hospitals and community resources.
• Participate in interdisciplinary care conferences.
• Educate patients and families on available services after discharge.

Skills

Bilingual English/Spanish

Interpersonal communication

Care coordination

Documentation proficiency

Local travel

Education

AS/BS in Social Work or related field

Tools

Electronic Health Records (EHR)

Care management software

Job description

You are joining a team shaped by five generations of care — where values like trust, transparency, and collaboration guide everything we do. Whether you serve patients directly or support those who do, your role helps bring out the courage in others.

Description

Job Title

Patient Navigator

Job Category

Field Primary – Support

Job Purpose

You are joining a team shaped by five generations of care — where values like trust, transparency, and collaboration guide everything we do. Whether you serve patients directly or support those who do, your role helps bring out the courage in others.

Job Summary

The Patient Navigator works alongside home health and hospice teams to support medically and socially complex patients through safe, coordinated transitions from hospital to home and community, providing ongoing care management and support throughout the episode of care.

Job Specific Duties

• Identify patients being discharged from hospital settings who are appropriate for home health or hospice services and require transitional support due to medical or social complexity.
• Coordinate directly with hospital discharge planners, case managers, and social workers to facilitate timely and safe transitions to home-based care.
• Conduct post-discharge follow-up with patients and families to assess transition success, address barriers, and connect them with appropriate community resources.
• Collaborate with home health and hospice clinical teams to ensure continuity of care plans and alignment of patient goals across the care continuum.
• Assess patient's social determinants of health — including housing stability, transportation, food access, caregiver support, and financial barriers — and connect them with available resources.
• Provide ongoing support and advocacy for patients and families navigating complex care systems for the duration of the care episode.
• Maintain accurate and timely documentation of patient interactions, referrals, follow-up activities, and outcomes in appropriate clinical and administrative systems.
• Build and maintain relationships with hospital partners, community organizations, and social service agencies to support a robust referral and resource network.
• Participate in interdisciplinary care conferences, Joint Operating Committee meetings, and other events to represent the patient's social and navigational needs.
• Track patient outcomes and transition metrics to support quality improvement efforts and demonstrate program value.
• Communicate proactively with care team regarding high-risk patients or barriers that may affect care outcomes or patient safety.
• Educate patients and families on available services, care expectations, and how to access support after discharge.
• Perform other related duties as assigned to support the home health and hospice transition-of-care program.

Other Duties

• Maintain accurate documentation and timely data entry in appropriate systems
• Communicate clearly with team members and community partners to support continuity of care
• Participate in departmental meetings, trainings, and process improvement efforts
• Maintain compliance with HIPAA and all company privacy and confidentiality standards
• Foster a respectful, collaborative, and organized work environment in the field
• Work independently with minimal daily oversight and demonstrate initiative in completing responsibilities
• Provide courteous, timely, and professional customer service to internal and external stakeholders
• Exhibit adaptability to changing responsibilities and flexibility in completing assignments
• Possess basic computer proficiency and use of technology in daily responsibilities
• Adhere to all organizational policies, including job descriptions, mission, and the Employee Handbook
• Communicate and interact professionally and respectfully with others to support team goals
• Perform all other duties as assigned and as required to effectively discharge the responsibilities of the position and are in the best interests of the company

Work Environment

Primarily works in an office

Supervisor

Executive Director - Sierra Health Care

Supervises

None

Risk Level

Field-based; patient interaction with some injury risk

Requirements

Qualifications

• Associate's or bachelor's degree in social work, healthcare administration, nursing, public health, or a related field preferred; equivalent combination of education and experience considered.
• Minimum 2 years of experience in healthcare, care coordination, case management, social services, or a related field preferred.
• Experience working with medically and socially complex patient populations, including knowledge of social determinants of health and community resource navigation.
• Familiarity with home health, hospice, or post-acute care settings preferred; experience with hospital discharge planning or care transitions a plus.
• Bilingual fluency in English and Spanish strongly preferred; the communities served include a significant Spanish-speaking population, and the ability to communicate directly with patients and families in their preferred language greatly enhances the effectiveness of this role.
• Strong interpersonal and communication skills, with demonstrated ability to build trust with patients, families, and clinical partners across diverse settings.
• Ability to work independently in the field with minimal daily supervision while maintaining accountability to team goals and documentation standards.
• Basic proficiency with electronic health records, care management platforms, or similar documentation systems; comfort learning new technology tools.
• Valid driver's license and reliable transportation required; ability to travel locally in varying weather conditions.
• Working knowledge of HIPAA and commitment to maintaining patient privacy and confidentiality.
• Alignment with CareM's mission to bring out the courage in others — demonstrated through empathy, advocacy, and a genuine commitment to serving vulnerable populations.

Physical Requirements

• Must be able to stand, walk, bend, and assist with mobility or equipment as needed. Requires the ability to perform heavy lifting and to travel locally in various weather conditions.