RN-Patient Navigator

Catholic Health System • Rockville Centre, NY

90d • $52 - $71

About The Position

The RN Patient Navigator plays a key role in promoting high quality, patient-centered care by coordinating transitional care, preventive services, and chronic disease management. This position focuses on guiding patients through the healthcare system, ensuring timely follow-up, improving health outcomes, and reducing avoidable hospital readmissions. The RN Patient Navigator will support primary care teams by facilitating access to care, enhancing communication between providers, and engaging patients through telehealth and community-based outreach.

Requirements

• Current RN license in the state of New York.
• Minimum 2 years of experience in care coordination, population health, or primary care preferred.
• Experience with Medicare Annual Wellness Visits, transitional care, and chronic care management.
• Strong working knowledge of electronic health records (EHR) and care management tools.
• Excellent interpersonal, organizational, and critical thinking skills.
• Ability to work independently and as part of a multidisciplinary team.
• Knowledge of quality metrics, care gaps, and risk adjustment coding is a plus.
• Bilingual - Spanish speaking a plus.

Nice To Haves

• Experience in telehealth platforms and patient engagement via remote technology.
• Familiarity with PHQ-9, SDOH screenings, and DME ordering processes.
• Understanding of healthcare resources within the community setting.

Responsibilities

• Assist in scheduling timely Transition of Care (TOC) visits for unattached Emergency Department (ED) and hospital discharges.
• Collaborate with hospital discharge planners and primary care providers to ensure continuity of care.
• Manage and maintain databases of Medicare patients eligible for Annual Wellness Visits (AWVs).
• Conduct telemedicine AWVs, including screening tools (PHQ-9, Social Determinants of Health, and Cognitive Risk Assessment).
• Perform Durable Medical Equipment (DME) assessments and ordering.
• Conduct medication reconciliation and prior authorizations.
• Obtain medical records, labs, and imaging pre-visit.
• Act as a point of contact and care coach for high-risk patients.
• Conduct proactive care coordination, including appointment scheduling, referrals, and specialist/imaging coordination.
• Monitor patients via telecommunication for signs of decompensation and escalate care when needed.
• Support medication adherence and provide disease-specific education.
• Assist with outreach initiatives to close preventive and chronic care gaps.
• Maintain and manage care management registries to identify and monitor patients needing follow-up.
• Document interventions and outcomes in the electronic health record (EHR) and report metrics as required.
• Support providers by managing inboxes for abnormal labs and initiating follow-up per physician directive.
• Coordinate care team communications and assist with patient queries and care instructions.

Benefits

• Generous benefits packages.
• Generous tuition assistance.
• Defined benefit pension plan.
• Culture that supports professional and educational growth.

What This Job Offers

• Industry: Hospitals