Care Navigator

🔥 0 minutes ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $57.2k - $73.1k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🚫👨‍🎓 No degree required

👻 Ghost score 0%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.Why this score:

• Just posted.
• Jobs at this company usually fill in 34 days.

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Monogram Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2019

💼 Consulting

🛡️ Insurance

📦 Logistics

Consulting • Insurance • Logistics

Monogram Health is a leading multispecialty provider that delivers in-home, evidence-based care and benefit management for patients with complex, multiple chronic conditions, with a strong focus on chronic kidney disease and related metabolic, cardiovascular, pulmonary, and behavioral health needs. The company coordinates multispecialty clinical teams (nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care), provides 24/7 home-based support including home dialysis and medication management, and partners with payers and physician groups to improve outcomes, reduce hospitalizations, and lower costs.

📋 Description

• Conduct proactive outreach to patients to identify unmet social needs using the nine-domain CMS-aligned SDoH assessment • Engage patients in goal-oriented conversations to identify priorities, assess readiness, and build rapport • Identify and document SDoH needs across all nine domains • Research and connect patients to community-based resources, local programs, public benefits, and referral partners • Guide patients through application, referral, and enrollment processes • Follow up to verify resource utilization, confirm access, and ensure complete resolution of social barriers • Own each SDoH case from initial identification through confirmed closure • Document interventions, follow-up contacts, and resolution outcomes in Pt. 360 • Keep unresolved or partially resolved cases active and tracked • Drive timely closure of open SDoH cases and escalate stalled cases • Partner with pod clinicians including RNs, APPs, and BHCs • Escalate clinical, behavioral health, safety, or high-risk psychosocial concerns • Participate in interdisciplinary huddles and complex case discussions • Monitor ongoing SDoH needs until resolution • Support internal quality improvement initiatives and SDoH data collection efforts

🎯 Requirements

• High school diploma or GED • Minimum of (2) years of experience in care coordination, patient navigation, community health, or social services support • Demonstrated communication and relationship building skills • Comfort working with diverse populations and complex social needs • Ability to manage multiple priorities in a fast-paced environment • Bachelor’s degree in public health, human services, social sciences, or related fields is preferred • Experience working with Medicaid, Medicare, or value-based care populations is preferred • Familiarity with community resources and benefit programs is preferred • Bilingual language skills are preferred

🏖️ Benefits

• Medical, dental, and vision insurance • Employee assistance program • Employer-paid and voluntary life insurance • Disability insurance • Health and flexible spending accounts • 401k with employer match • Financial wellness resources • 20 PTO days • 7 paid holidays • 1 floating day • Paid parental leave • Work life assistance resources • Physical wellness perks • Mental health support • Employee referral program • BenefitHub for employee discounts

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