Care Navigator

Monogram Health

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

Posted 11/11/2026full-timeRemote • 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 Social Determinants of Health (SDoH) assessment and care coordination, effectively engaging patients and connecting them with community resources while managing complex social needs. Proficient in documentation and follow-up processes to ensure resolution of social barriers.

Highest-signal resume keywords

Social Determinants Of Health (SDoH) AssessmentCare CoordinationCommunity Resource NavigationPatient EngagementBilingual Communication

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

DocumentationCase ManagementResource Utilization TrackingApplication AssistanceReferral Coordination

Soft Skills

Communication SkillsRelationship BuildingMultitaskingCultural Competence

Tools & Technologies

Pt. 360

Industry Keywords

MedicaidMedicareValue-Based CarePublic HealthHuman ServicesSocial Services

About the role

Key responsibilities & impact

Conduct proactive outreach to identify unmet social needs using the nine-domain CMS-aligned SDoH assessment
Engage patients in goal-oriented conversations and build rapport as a reliable non-clinical support contact
Identify and document SDoH needs across nine domains
Research and connect patients with community resources, local programs, public benefits, and referral partners
Guide patients through application, referral, and enrollment processes
Follow up to verify resource utilization, access, and resolution of social barriers
Own each SDoH case from identification through confirmed closure
Document interventions, follow-ups, and outcomes in Pt. 360
Keep unresolved or partially resolved cases active and tracked
Drive timely case closure and escalate stalled cases
Partner with RNs, APPs, and BHCs to coordinate patient SDoH needs
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 quality improvement initiatives and SDoH data collection

Requirements

What you’ll need

High school diploma or GED
Bachelor’s degree in public health, human services, social sciences, or related fields is preferred
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
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 employee discounts