Chronic Care Patient Navigator

Living Water Clinic • Lindsay, CA

16h

About The Position

Living Water Clinic – Clinica Agua Viva is seeking a highly organized and detail-oriented Chronic Care Patient Navigator to support its chronic care programs. The position helps patients access services, schedule appointments, use remote monitoring devices, and remain engaged in their care. It serves as a liaison among patients, LWC staff, and APEX to coordinate follow-up, communicate concerns, and resolve service barriers under the direction of the Chronic Care Management Specialist.

This is a patient support and coordination role. Clinical assessment, interpretation of readings, medication advice, and treatment decisions must be referred to licensed clinical staff. The role requires timely outreach and follow-up, accurate documentation, reliable tracking and resolution of device and vendor issues, prompt escalation of clinical concerns, and respectful patient service and teamwork. The position may provide coverage across LWC locations as assigned.

Living Water Clinic describes itself as dedicated to compassionate, comprehensive healthcare for its community, guided by faith and service. It welcomes qualified applicants and states that it is an equal opportunity employer committed to diversity, equity, and inclusion.

Requirements

• High school diploma or equivalent required.
• Strong communication, organization, customer service, and follow-through skills.
• Comfort using electronic health records, spreadsheets, and remote monitoring technology.
• Ability to protect patient confidentiality and follow HIPAA requirements.
• Ability to refer clinical assessment, interpretation of readings, medication advice, and treatment decisions to licensed clinical staff.
• Ability to sit for extended periods and use a computer regularly.
• Clear verbal communication and good hearing for phone and in-person interactions.

Nice To Haves

• Experience in patient scheduling, medical office support, patient navigation, or care coordination.
• Medical assistant, community health worker, or related training.
• Bilingual English/Spanish.
• Working knowledge of medical terminology and healthcare workflows.
• Customer-focused, empathetic, patient-centered, adaptable, flexible, professional, ethical, and able to work independently as well as with a team.
• Exceptional organizational and multitasking abilities; clear, compassionate communication; proficiency with scheduling and EHR systems; accuracy maintaining calendars and patient information; and ability to manage multiple priorities efficiently.

Responsibilities

• Contact patients to introduce chronic care services and coordinate enrollment according to approved workflows.
• Explain program participation, expectations, and next steps using approved materials.
• Follow up with patients who miss appointments, need assistance, or are not submitting device readings.
• Identify barriers such as language, transportation, technology, or difficulty reaching the care team and connect patients with appropriate support.
• Provide respectful service and communicate in a patient’s preferred language when qualified.
• Schedule initial visits, quarterly RPM reviews, follow-up appointments, and device education visits.
• Coordinate appointments with APEX providers and LWC clinic teams; provide reminders, reschedule missed visits, track outstanding follow-up needs, and coordinate warm transfers according to established workflows.
• Assist with distributing and setting up blood pressure monitors, glucose meters, scales, and pulse oximeters.
• Teach patients to use and care for devices using approved instructions and teach-back.
• Troubleshoot basic device, connectivity, and reading-transmission issues, referring unresolved problems to APEX technical support.
• Coordinate replacement devices, supplies, returns, and retrieval of unused equipment; maintain accurate device assignment and inventory records.
• Route reported symptoms, abnormal readings, and clinical questions promptly to licensed clinical staff according to escalation procedures.
• Serve as a daily operational liaison between APEX and LWC, communicating scheduling needs, patient concerns, device issues, enrollment updates, and unresolved follow-up items.
• Track issues through resolution and escalate delays to the Care Management Lead.
• Help maintain accurate clinic, provider, and patient assignments across approved systems; participate in vendor meetings and communicate assigned action items.
• Document patient contacts, outreach attempts, education, scheduling actions, device assistance, and follow-up needs in designated systems.
• Maintain work queues, outreach logs, device trackers, and issue trackers; assist with reports on enrollment, engagement, completed visits, missed appointments, and device use.
• Flag possible duplicate program enrollment, insurance changes, and enrollment discrepancies for review.
• Follow approved patient consent, enrollment, and disenrollment processes; route eligibility and billing questions to designated staff.
• Coordinate with providers, medical assistants, scheduling, billing, ECM, and CHW teams to support consistent patient follow-up.
• Assist with preparing patient education materials and organizing program supplies.
• Participate in training, workflow updates, quality improvement activities, and team meetings.
• Provide coverage across LWC locations as assigned and perform other related duties as assigned.

Benefits

• Competitive salary.
• Health insurance.
• Dental insurance.
• Vision insurance.
• 401(k) matching.
• Paid time off.
• Opportunity to join a growing healthcare organization and gain experience in a mission-driven clinical setting.

What This Job Offers

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