Patient Care Navigator II (One Health Complete)

Job Description

Job Description

Description:

The Patient Care Navigator (PCN) is an on-site clinical operations resource for One Health Complete (OHC) within partner Skilled Nursing Facilities (SNFs). The PCN serves as the physical bridge between the SNF interdisciplinary team, OHC's care management team, and patients during their SNF stay and through the post-discharge transition.

This is a high-autonomy, high-accountability role for a SNF experienced individual who is comfortable working independently inside a third-party facility and partnering closely with SNF Social Workers, patients and their families, and One Health clinical staff. PCN level IIs will manage their own SNF, oversee PCN level I’s at other SNF facilities, and review potential escalations.

Key Responsibilities:

Patient Identification & Enrollment

• Partner with the SNF Social Worker and admissions team to coordinate intake on new admissions flagged by OHC
• Describe the OHC multispecialty care program to patients, obtain consent, and set patient and family expectations
• Schedule the qualifying home televisit and chart-review encounters between the patient and the OHC remote clinicians

Care Coordination & Workflow Execution

• Gather information about patients across OHC and SNF EMRs
• Maintain accurate documentation of patient touchpoints, consent, and discharge instructions inside OHC’s EMR
• Interact with patients bedside at SNF to assess and educate about OHC

Cross-Functional Collaboration

• Serve as the trusted on-site liaison between the SNF interdisciplinary team (Social Work, DON, Rehab, Pharmacy, etc.) and OHC’s care management team
• Surface workflow friction, facility-level adoption barriers, and patient-experience gaps to OHC leadership
• Be able to manage and nurture PCN level I’s who are managing their own SNFs while managing your own
• Engage in continuous process improvement to the PCN workflow and role structure

• 2+ years of SNF experience as a Licensed Practical Nurse/Registered Nurse or Licensed Clinical Social Worker.
• Demonstrate working knowledge of SNF workflows including admissions, MDS coordination, discharge planning, and the role of the SNF interdisciplinary team
• Experience navigating at least one major SNF EHR system (PointClickCare, MatrixCare, or DocNow).
• Familiarity with Medicare Part A SNF benefit periods, transitions of care, and post-acute readmission drivers

Core Competencies

• High autonomy and sound judgment in an embedded, single-resource role
• Strong relationship-building skills with SNF Social Workers, DONs, and Co-Medical Directors
• Comfort with technology-forward workflows: AI alert dashboards, real-time data feeds, and digital consent
• Excellent verbal and written communication, including SBAR-style clinical escalation
• Mission alignment with closing the post-acute care cliff and improving access to care

Physical & Schedule Requirements

• On-site presence at the assigned SNF five days per week, with occasional flexibility for discharge timing
• Travel between Barrington and Huntley, IL
• Reliable transportation between the assigned SNF and occasional OHC team meetings