Central Health


Req No.
CommUnityCare Health Centers
North Central
1210 Braker Lane
Medical Services
Regular Full-Time
Shift Days
Shift Hours


In collaboration with patients, families (as defined by the patient) and staff across all disciplines and departments is responsible for facilitating the coordination of care for patients and serving as a resource for providers and clinic staff.  This position may be based in a clinic or in a central patient navigation center.


  • Initiate patient contact for follow-up and continuation of care in a medical home after hospitalizations and ER visits.
  • Provide telephonic coaching, information, and educational materials and resources to patients as needed.
  • Assist patients with securing appropriate care and services within the health system and community and facilitate patient access to medical home providers, staff and resources.
  • Serve as the primary contact for external providers (hospital, specialty and ER) and patients upon discharge from hospital or ER.
  • Link patients to appropriate resources, services and support for continuation and coordination/navigation of care.
  • Follow patients throughout the care continuum, including inpatient admissions, and collaborate with inpatient care management resources.
  • Assist with the identification of patients in the practice with need for care coordination and navigation.
  • Facilitate appointments for consults and support services within established service standards, including social workers, dietitians, physician, etc.
  • May be the point of contact for after hours care for CommUnityCare patients
  • Perform other duties as assigned.         



  • Proactively follow-up with patients and care providers.
  • Stay up-to-date on local support and service provider information and contacts.
  • Complete all direct and indirect care documentation in timely manner and ensure patient records are current and complete.
  • Attend periodic informational huddles, meetings, patient conferences, or planning sessions.  These may be related to quality assurance, patient care and other related topics within the clinic.
  • Participate in quality strategies to evaluate compliance with evidence-based guidelines, standards and to identify opportunities to improve patient outcomes
  • Ensure all tasks provided and associated with patient care, patient administrative processes and related duties comply with all regulatory and accreditation standards including The Joint Commission and CommUnityCare Standard Operating Procedures and CommUnityCare Policies and Procedures.
  • Establish and maintain positive working relationships with key customers (physicians, office staff, diagnostic staff, nurses, radiology staff, and social services staff).
  • Interact respectfully and collaboratively with patients and their families, striving to develop favorable relationships with families.
  • Collaborate with all members of the care team in providing patient-centered care.


  • High level of skill at building relationships and providing excellent customer service.
  • Strong attention to detail and accuracy.
  • Ability to utilize computers for data entry and information retrieval.
  • Excellent verbal and written communication skills.
  • Ability to work with a diverse population.
  • College degree in social services or related field preferred. Any combination of related experience and education may be considered.
  • Experience in the healthcare field (working directly with patients preferred).
  • Experience in a care coordination role highly desirable.




  • College degree in social services or related field preferred. Any combination of related experience and education may be considered.

Knowledge and Experience

  • Experience in the healthcare field (working directly with patients preferred).
  • Experience in a care coordination role highly desirable.


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