Care Coordination & Navigation Specialist (CCNS)

Ophelia

7h • Remote

About The Position

Ophelia is seeking an experienced Care Navigator or Care Coordinator to join its virtual program serving patients in Pennsylvania, New Jersey, New York, and Delaware. This role involves direct patient engagement and case management, acting as a first point of contact for patients and developing individualized care plans. The specialist will address patient needs, which may include insurance issues, program waitlists, or resource availability across different counties. The role requires flexibility in handling fast-turnaround patient support, such as scheduling and troubleshooting, as well as more in-depth research and case resolution. The care navigation program primarily supports patients in Ophelia's Centers of Excellence in Pennsylvania, with virtual navigation primarily conducted via SMS, supplemented by phone, EMR messaging, and Zoom. The specialist will collaborate closely with a clinical team, documenting all work within shared patient records. This position is ideal for someone comfortable building trust through consistent patient contact, adept at managing high-volume triage and focused casework, and understanding the importance of good documentation in a virtual care setting. The role reports to the Manager of Care Navigation.

Requirements

• 2+ years in care navigation, case management, community health, or patient-facing customer support in a healthcare setting — with meaningful experience delivered virtually or over the phone
• Experience with SDOH navigation (housing, transportation, food access, behavioral health, benefits enrollment) or experience delivering outstanding patient experience in a high-volume, multi-channel environment (ideally with a ticketing system) — we're looking for strength in at least one, with willingness to grow into both
• Working knowledge of, or ability to quickly learn, community resources, programs, and systems in PA, NJ, NY, and/or DE
• Proficient and comfortable using EMR, ticketing systems, or care management platforms as primary daily tools, with strong overall tech savviness
• Strong written communication skills — clear and professional with patients over text, phone, and other channels
• Ability to independently manage a caseload, prioritize across multiple channels (SMS, EMR, phone, Slack) and competing needs, and track work through to resolution
• Strong organizational skills and a keen eye for detail, including accuracy in patient records
• High school diploma or GED required; associate's or bachelor's in social work, public health, or human services strongly preferred
• Demonstrated ability to work with diverse patient populations with cultural humility — adapting communication and approach to each patient's background, values, and circumstances
• A bias for action: proactively taking on work without prompting, and adapting well to a fast-changing environment

Nice To Haves

• Experience in a Center of Excellence or specialty care program serving patients with complex, co-occurring needs
• Familiarity with Medicaid populations and managed care requirements in NJ or PA
• Experience navigating drug & alcohol, psychiatric care, or specialty behavioral health resources
• Familiarity with trauma-informed care, harm reduction philosophy, and motivational interviewing as frameworks that shape how you listen, communicate, and engage

Responsibilities

• Serve as a first point of contact for inbound patient communication, quickly assessing urgency and either resolving the request or triaging it to the appropriate team member
• Support scheduling of visits with the clinical team, help improve visit attendance, and coordinate UDS logistics
• Maintain and update patient data accurately across systems
• Troubleshoot technology issues patients encounter with our platforms
• Practice active listening, empathy, and solution-focused approaches — providing emotional support, de-escalation, and education as needed
• Manage an active caseload of patients, developing and maintaining individualized care plans
• Reach patients by SMS and phone to assess needs, clarify barriers, and keep cases moving — building rapport through consistency rather than long sessions
• Research targeted resources for each patient based on their specific situation — insurance status, location, income, and the actual barrier they're facing
• Follow cases through to confirmed resolution
• Escalate the most complex cases for specialist support, and facilitate step-down back to your caseload when appropriate
• Maintain current knowledge of resources, programs, and eligibility rules across PA, NJ, NY, and DE
• Navigate public benefit systems including Medicaid, SNAP, transportation assistance, housing programs, and behavioral health services
• Build relationships with community-based organizations and providers in the region
• Provide warm handoffs, direct scheduling, or guided next steps based on what each patient needs
• Document your work in the EMR as you go — activity, resource decisions, status changes, and next steps — so the clinical team always has the full picture
• Collaborate with providers through shared patient records, escalating clinical concerns, safety issues, and urgent needs to the appropriate clinical team member promptly and with the right context
• Follow established processes and protocols to ensure patients receive consistent, high-quality care
• Participate in team meetings and case reviews

Benefits

• Competitive medical, vision, and health insurance (many plans are fully covered for the employee!)
• Start with 20 days (4 weeks) of PTO, increasing to 5 weeks after 2 years and 6 weeks after 5 years of tenure
• 10 company holidays
• Work From Home Stipend
• 401k Contribution Platform
• Life insurance
• Short and long term disability
• Financial wellness
• Virtual primary care

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED