Regional Care Transition Navigator

Healing-Partners; Erie (Erie County); On-site; USD 52,000 - 68,000; Full time

Job summary

Healing-Partners is seeking a Regional Patient Navigator to support patients transitioning from SNFs to post-discharge care at home. This on-site role partners with interdisciplinary teams to identify needs, coordinate services, and ensure safe, timely transitions.

Ideal candidates have a bachelor’s degree and experience in case management, social work, or care coordination. Travel within the territory is required; licensure is not mandatory.

Qualifications

• Bachelor’s degree required; Master’s degree (MSW, MHA, or related field) preferred.
• Background in case management, care coordination, social work, patient advocacy, or related healthcare roles.
• Clinical licensure not required.

Responsibilities

• Establish a consistent presence within assigned skilled nursing facilities to support post-discharge planning and care transitions
• Identify patients who may benefit from post-acute health services through collaboration with nursing, social services, and discharge planning teams
• Educate patients and families on available care options and support informed decision-making for post-discharge services
• Coordinate referrals and facilitate timely transitions to appropriate post-acute providers
• Serve as a liaison between SNF staff and post-acute care partners to ensure clear communication and continuity of care
• Document patient interactions, referrals, and outcomes in accordance with organizational and regulatory standards
• Build and maintain strong professional relationships within facilities through reliability, responsiveness, and ethical conduct
• Travel independently between assigned facilities within the designated territory

Skills

Interpersonal skills

Communication

Organizational skills

Autonomy

Time management

Patient engagement

Collaborative mindset

Relationship-building

Education

Bachelor's degree

Master's degree (MSW, MHA, or related field)

Job description

Healing-Partners is seeking a Regional Patient Navigator to support patients transitioning from SNFs to post-discharge care at home. This on-site role partners with interdisciplinary teams to identify needs, coordinate services, and ensure safe, timely transitions.

Ideal candidates have a bachelor’s degree and experience in case management, social work, or care coordination. Travel within the territory is required; licensure is not mandatory.