Care Navigator

Partner closely with assigned GGH Nurse Practitioners (NPs) to co-manage their patient panel, serving as the day-to-day coordination hub for scheduling, care follow-through, and patient communication.

Build and optimize driving routes for GGH Nurse Practitioners completing home visits, maximizing time spent with patients.

Coordinate patient cancellations, reschedules, and add-on visits with the NP to ensure continuity of care and efficient schedule management.

Retrieve and reconcile medical records from outside providers, hospitals, health systems, and community organizations to ensure the care team has a complete and current view of each patient’s health history.

Manage patients post-discharge from hospital or skilled nursing facility settings, coordinating timely follow-up visits and facilitating care plan transitions to reduce readmission risk.

Follow up with patients on outstanding provider orders — including lab work, imaging, specialist referrals, and durable medical equipment — ensuring completion and routing results back to the care team.

Coordinate referrals and activities for high-risk programs, facilitating smooth transitions between care settings and service providers.

Support the care team in identifying and closing quality gaps, including HEDIS measures and chronic disease management needs.

Handle protected health information (PHI) with discretion, adhering to HIPAA standards and GGH privacy policies at all times.

Maintain timely, accurate, and thorough documentation of all patient interactions, outreach attempts, care coordination activities, and follow-up plans.

Build strong, positive working relationships with GGH Nurse Practitioners and the Patient Outreach Team, and maintain professional communications with client partners and the broader care team.

Participate in interdisciplinary care team meetings, contributing patient updates and coordinating action steps across team members.

Maintain collaborative relationships with clinicians and the leadership team to support the development of new programs aimed at improving patient engagement, care coordination, and health outcomes.

Other duties as assigned.

Completing 50–100 outbound calls per day.

Achieving conversion rate expectations for AWV scheduling and preventative care outreach.

Successfully managing post-discharge follow-up to minimize care gaps and reduce avoidable readmissions.

Timely retrieval and reconciliation of outside medical records to support care team decision-making.

High completion rates on outstanding provider orders through consistent, proactive patient follow-up.

Building and maintaining strong professional relationships with the Care Navigator team and GGH Nurse Practitioners.

Timely, accurate, and thorough documentation in all systems of record.

Meeting and exceeding call quality standards.

8 hours per day seated at a home-office desk, working in front of a computer using a keyboard.

Two 10-minute breaks throughout the day, as well as a one-hour meal break.