Care Coordinator/Care Navigator II (non-RN)

Mosaic Health•Jacksonville, FL

7d•$21 - $31•Remote

About The Position

The Care Coordinator/Care Navigator II supports patients and families with routine and moderately complex navigation needs. The role coordinates appointments, communication among care team members, community resources, follow-up activities, and transitions across care settings. It helps resolve common access barriers and supports patients in understanding next steps related to care, payer requirements, and internal services. Working under the direction of the RN Care Manager and in collaboration with primary care providers, patients, caregivers, and interdisciplinary team members, this position supports outpatient care management activities. Responsibilities include care coordination, transitions of care, chronic disease management, patient outreach, resource navigation, and documentation to improve patient outcomes, reduce avoidable utilization, and enhance the patient experience. The position may be filled by a Licensed Practical Nurse (LPN) or an experienced Medical Assistant (MA) with strong clinical knowledge and care coordination experience. The role performs defined clinical support processes under moderate supervision, applying working knowledge to routine and moderately non-routine situations. It communicates with patients, members, and clinical staff, and escalates clinical concerns to the RN Care Manager or provider as appropriate. The position is primarily remote, may be based in an MPG main office and/or outpatient clinic, and involves telephonic patient outreach, care coordination, and occasional interaction with community agencies and healthcare facilities. The anticipated base salary range is $20.90 to $31.35. Actual compensation may depend on experience, skills, qualifications, geographic location, internal equity, and business needs.

Requirements

One of the following: a current Florida Licensed Practical Nurse (LPN) license, or a Certified Medical Assistant (CMA/RMA) or equivalent Medical Assistant certification from an accredited program; the MA credential is listed as preferred.
LPN applicants must have an active, unrestricted Florida LPN license.
Medical Assistant applicants must maintain current certification, if applicable.
Experience using electronic health records (EHR) is required.
Strong organizational and time-management skills.
Excellent verbal and written communication skills.
Ability to build rapport and effectively engage patients and caregivers.
Knowledge of care coordination principles, transitions of care, and population health management.
Understanding of chronic disease management and preventive care strategies.
Ability to identify barriers to care and coordinate appropriate interventions.
Strong documentation and computer skills.
Ability to work independently while collaborating closely with the RN Care Manager and interdisciplinary care team.

Nice To Haves

Current BLS certification preferred.
At least three years of clinical healthcare experience in a physician practice, outpatient clinic, population health, care management, case management, transitional care, home health, or related setting preferred.
Experience working with chronic disease management and high-risk patient populations preferred.
Bilingual skills are a plus.

Responsibilities

Assist the RN Care Manager in implementing and monitoring individualized patient care plans.
Review patient charts monthly to identify care gaps, preventive care needs, and opportunities for intervention.
Monitor and track follow-up appointments, referrals, diagnostic testing, and care plan goals.
Coordinate services among primary care providers, specialists, hospitals, skilled nursing facilities, home health agencies, and community organizations.
Collaborate with the healthcare team to support continuity of care across settings.
Conduct telephonic outreach to patients and caregivers as directed by the RN Care Manager.
Assess barriers to care, including transportation, medication access, financial concerns, health literacy, and social determinants of health.
Encourage patient participation in care plans, preventive services, and chronic disease management programs.
Build and maintain trusting relationships with assigned patients and caregivers.
Support transitions of care after emergency department visits, hospitalizations, and skilled nursing facility stays.
Assist with post-discharge follow-up, appointment scheduling, medication reconciliation support, and identification of ongoing care needs.
Coordinate necessary services, equipment, and community resources before or following discharge.
Communicate pertinent information to providers and care team members to facilitate timely interventions.
Reinforce education provided by the RN Care Manager and providers on chronic disease management, medication adherence, preventive health, self-management, and community resources.
Provide information on prescription assistance programs, transportation services, community resources, and support groups as appropriate; refer to ACO pharmacy to assist with PAP.
Maintain accurate, timely, and complete documentation in the electronic health record.
Obtain and upload medical records, discharge summaries, consult notes, and test results from hospitals, specialists, skilled nursing facilities, and other providers.
Track care management activities, outreach attempts, patient outcomes, and quality metrics.
Assist patients in accessing appropriate clinical, social, behavioral health, and community-based services.
Maintain knowledge of local, state, and federal community resources.
Advocate for patient needs and promote patient-centered care.
Escalate clinical concerns to the RN Care Manager or provider as appropriate.