Care Navigator

Monogram Health

. Conduct proactive outreach to patients to identify unmet social needs using the nine-domain CMS-aligned SDoH assessment .

Posted 11/10/2026full-timeRemote • Texas • United StatesJuniorMid-Level💰 $57,165 - $73,130 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in conducting social determinants of health (SDoH) assessments and connecting patients to community resources while managing care coordination and patient navigation. Proficient in documenting interventions and collaborating with interdisciplinary teams to address complex social needs.

Highest-signal resume keywords

SDoH AssessmentCare CoordinationCommunity Resource NavigationPatient EngagementBilingual Communication

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Social Determinants Of HealthCare CoordinationPatient NavigationDocumentationResource Utilization

Soft Skills

Communication SkillsRelationship BuildingPrioritizationRapport BuildingComfort With Diverse Populations

Tools & Technologies

Pt. 360

Industry Keywords

MedicaidMedicareValue-Based CareCommunity HealthSocial Services

About the role

Key responsibilities & impact

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

What you’ll need

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

Comp & perks

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