SNF at Home Navigator

Job Description

Job Description

Description

About the Role

The SNF at Home Navigator is responsible for supporting patients and families through the transition from an acute hospital setting or traditional Skilled Nursing Facility (SNF) setting into a SNF at Home program. This patient- and family-facing role collaborates with patients, caregivers, hospitals, SNFs, care teams, and operational stakeholders to provide education, care coordination, and engagement that supports successful transitions to home-based care. The Navigator serves as a trusted point of contact throughout the transition process, helping patients understand available care options, navigate program enrollment, and ensure a positive care experience while supporting organizational goals related to member engagement, access, and care coordination.

• Put Patients First
• Empower Entrepreneurial Provider and Care Teams
• Operate with Integrity & Excellence
• Be Innovative
• Work As One Team

Patient & Family Engagement

• Contact patients and family members to discuss SNF at Home program options, eligibility requirements, and enrollment opportunities.
• Educate patients and caregivers on the benefits, expectations, services, and logistics of receiving skilled nursing-level care in the home setting.
• Serve as a compassionate and professional point of contact for patients and families throughout the transition process.
• Support patient and caregiver understanding of care plans, program services, and next steps related to home-based care.
• Conduct outreach and follow-up communications to promote patient engagement and successful program participation.
• Navigate sensitive conversations with patients and families while maintaining a patient-centered approach.

Care Coordination & Transition Management

• Coordinate outreach and transition activities for patients being discharged directly into a SNF at Home program or transitioning from a traditional SNF setting to home-based care.
• Collaborate with clinical teams, case managers, discharge planners, SNF staff, and Home Care Advantage team members to support seamless patient transitions.
• Facilitate communication between patients, families, providers, facilities, and internal stakeholders throughout the transition process.
• Assist with scheduling activities, transition planning, follow-up communication, and enrollment-related coordination.
• Identify barriers to successful transitions and escalate concerns to the appropriate team members.
• Support continuity of care through effective coordination and timely communication.

Field-Based Provider & Facility Engagement

• Conduct in-person visits at hospitals and Skilled Nursing Facilities throughout Rhode Island to meet with patients, caregivers, facility staff, and care teams.
• Build and maintain productive working relationships with discharge planners, case managers, SNF personnel, and healthcare providers.
• Represent the organization professionally during onsite meetings, educational discussions, and care transition activities.
• Support facility and provider engagement efforts that enhance awareness and adoption of SNF at Home services.
• Participate in meetings and outreach activities that support program growth and patient access.

Compliance & Operational Excellence

• Document patient interactions, outreach efforts, transition activities, and coordination notes accurately and timely.
• Maintain confidentiality and compliance with HIPAA requirements, organizational policies, and applicable healthcare regulations.
• Track outreach activities, enrollment progress, and transition outcomes using approved systems and tools.
• Support reporting, operational workflows, and administrative processes related to program performance and patient engagement.
• Participate in team meetings, training sessions, and organizational initiatives as required.
• Perform other duties and special projects as assigned.

Education

• Associate's degree in Nursing required.
• Bachelor's degree in Nursing, Healthcare Administration, Public Health, or a related field preferred.

Experience

• Registered Nurse (RN) required.
• Experience in healthcare administration, care coordination, case management, discharge planning, patient navigation, or customer service within a healthcare environment preferred.
• Experience working with patients and families during transitions of care preferred.
• Familiarity with Skilled Nursing Facilities (SNFs), post-acute care, home health, or home-based care programs preferred.
• Experience collaborating with hospitals, providers, case managers, or care coordination teams preferred.

License/ Certifications (if applicable)

• Active Registered Nurse (RN) license required.
• Valid driver's license and reliable transportation required.

Knowledge, Skills, and Abilities

• Strong knowledge of care coordination, patient engagement, transition of care, and healthcare service delivery models.
• Excellent verbal, written, and interpersonal communication skills.
• Ability to effectively communicate with patients, caregivers, providers, facility staff, and healthcare professionals.
• Strong organizational and time management skills with the ability to manage multiple priorities independently.
• Ability to work both remotely and independently in a field-based environment.
• Strong problem-solving skills and ability to navigate complex patient situations with professionalism and empathy.
• Proficiency with Microsoft Office applications and basic computer systems.
• Ability to maintain accurate documentation and manage confidential information appropriately.
• High degree of professionalism, accountability, integrity, and attention to detail.
• Commitment to providing exceptional patient and family experiences.

Preferred Qualifications

• Experience supporting post-acute care, discharge planning, care transitions, or home-based care programs.
• Experience working with Skilled Nursing Facilities, hospitals, home health agencies, or value-based care organizations.
• Experience in patient outreach, patient education, enrollment support, or care navigation roles.
• Experience collaborating with interdisciplinary care teams and community healthcare partners.
• Familiarity with healthcare documentation systems and care coordination platforms.

• This position is based in Rhode Island and supports SNF at Home program operations throughout the state.
• The role follows a hybrid work model and requires a combination of remote work and field-based travel.
• Travel throughout Rhode Island is required to support hospitals, Skilled Nursing Facilities, patient visits, and care transition activities.
• The employee must be able to attend meetings in person or virtually based on business needs.
• Work requires regular use of computers, telephones, mobile devices, electronic documentation systems, and virtual communication tools.
• The employee must maintain reliable transportation and the ability to travel independently throughout the assigned territory.
• The employee must comply with organizational policies and procedures regarding patient privacy, protected health information, HIPAA requirements, and all applicable federal and state regulations.