Care Navigator

• Provide specialized, harm-reduction-focused support to adults with HIV, adherence-related issues, or transferring care
• Meet with patients face to face, virtually, and by phone to provide education, counseling, support, and referrals
• Work as part of a multidisciplinary team with medical providers, community health workers, behavioral health staff, and other care team members
• Identify patients needing specialty adherence care and encourage appropriate referrals
• Systematically engage patients who are out of care and refer them to community agencies as needed
• Guide patients through Whitman-Walker and external services as a patient representative and advocate
• Make regular patient contact and develop individualized care plans supporting treatment adherence and long-term retention
• Identify and address barriers to retention and gaps in care
• Follow up with hospitalized patients, ER visitors, missed clinic visits, missed medication refills, or potentially non-adherent patients
• Coordinate with clinicians, case managers, behavioral health providers, and other healthcare providers
• Maintain accurate records in EMR and other data systems
• Prepare narrative, statistical, weekly, monthly, and annual reports
• Maintain a current resource list of community service organizations
• Participate in quality improvement activities, adherence training, and ongoing education
• Follow Whitman-Walker policies and procedures, including HIPAA requirements
• Perform other duties as assigned, including emergency-response tasks

• Develop, assess, and coordinate care management activities based on member needs
• Develop or contribute to personalized care plans/service plans
• Educate members and families/caregivers on services, benefit options, procedures, care options, referrals, and healthcare benefits
• Evaluate member needs, barriers to care, available resources, and facilitate plans for best outcomes
• Identify providers, specialists, and community resources needed for care
• Provide psychosocial and resource support to members/caregivers and care managers
• Coordinate between members/families/caregivers and care provider teams to ensure timely access to services
• Monitor progress toward care plan goals and member status or changes in condition
• Collaborate with healthcare providers on care plan revisions and refer members for further care management evaluation when appropriate
• Collect, document, and maintain member information and care management activities for regulatory compliance
• May perform on-site visits to assess member needs and collaborate with providers or resources
• Perform other duties as assigned and comply with all policies and standards

Care Navigator – Foster Care

• Serve as the first point of contact for patients or their families reaching out to Sailor Health
• Guide older adults and caregivers through the intake process
• Provide warmth, clarity, professionalism, and emotional support during initial conversations
• Coordinate patient care and help patients navigate the journey into care
• Match patients with the right therapist
• Help patients feel confident and understood throughout the intake and care journey
• Take initiative and help shape key processes as part of a small, agile team

• Expand the reach and impact of clinical hospice services by identifying and securing upstream referral sources and education opportunities
• Build relationships and drive appropriate hospice care for patients across physicians, providers, and hospitals
• Build upstream-referral relationships and transition hospice referrals from physicians and other referral sources
• Serve as a hospice clinical consultant and educator for hospital and physician care teams
• Review hospital clinical documentation, EMR, and HCHB records
• Engage patients and providers to build clinical patient profiles and admission assessments
• Identify decline patterns, including frequent hospitalizations and functional deterioration
• Educate care teams on hospice appropriateness
• Identify attending and consulting providers associated with referred patients
• Provide patient assessment, eligibility, discharge education, and awareness
• Collaborate with field sales representatives on consultative meetings with external care teams
• Initiate and maintain care team workflows for patient information, clinical assessment, documentation, consultation, education planning and delivery, and internal/external meetings
• Identify trends, needs, and partnership opportunities for earlier hospice engagement
• Foster trusted relationships with external care teams to improve patient outcomes and end-of-life satisfaction
• Communicate with hospital leadership and care coordination teams
• Organize, track, and prioritize comprehensive patient reviews
• Meet productivity requirements for medical-record review and hospital/provider consultation and education
• Collaborate cross-functionally with internal hospice departments and leadership teams
• Uphold hospice policies, privacy practices, and ethical guidelines
• Represent the organization professionally in hospitals, communities, and partner interactions
• Perform other duties as assigned

Transitional Care Navigator, RN

• Expand the reach and impact of clinical hospice services by identifying and securing new upstream referral sources and education and awareness opportunities
• Build relationships and drive appropriate and dignified hospice care for patients across physicians, providers, and hospitals
• Build upstream-referral relationships and transition hospice referrals from physicians and other referral sources
• Serve as hospice clinical consultant and educator, acting as an extension of hospital and physician care teams
• Review hospital clinical documentation, EMR, and HCHB
• Engage with patients and providers to build clinical patient profiles and clinical admission assessments
• Identify decline patterns such as frequent hospitalizations and functional deterioration
• Consult with hospital care teams by sharing clinical profiles and educating on hospice appropriateness
• Identify attending and consulting providers associated with referred patients to provide assessment, eligibility, and discharge education
• Collaborate with field sales representatives on consultative meetings with external care teams
• Initiate and maintain workflows for patient information, clinical assessment, documentation, consultation, education, and meetings
• Identify trends, needs, and partnership opportunities for earlier hospice engagement
• Foster relationships with external care teams to improve patient outcomes and end-of-life satisfaction
• Communicate with hospital leadership and care coordination teams
• Organize, track, and prioritize comprehensive patient reviews
• Meet productivity requirements, including timely medical-record review and hospital/provider consultation and education
• Uphold hospice policies, privacy practices, and ethical guidelines
• Represent the organization professionally in hospitals, the community, and partner interactions
• Collaborate with internal hospice departments and leadership teams
• Perform other duties as assigned

• Conduct high-volume outbound calls to engage patients and schedule healthcare services
• Coordinate care across multiple services, including mammograms, bone density screenings, and primary care connections, ensuring successful scheduling, follow-up, and completion
• Identify and address social determinants of health barriers by connecting patients to community resources such as transportation, housing, financial assistance, and food access
• Conduct patient assessments to understand clinical, social, and logistical barriers to care
• Educate patients on available healthcare services and community resources
• Build trust with patients and caregivers through clear, empathetic, and effective communication
• Proactively follow up with patients to ensure completion and close gaps in care
• Manage multiple workflows while maintaining accuracy and attention to detail
• Maintain detailed documentation of patient interactions and resource coordination in accordance with HIPAA and healthcare privacy standards
• Collaborate with clinical, operations, and support teams to ensure seamless patient experiences
• Escalate issues appropriately when patterns, risks, or blockers are identified
• Support additional projects and initiatives as needed

Care Navigator – Temporary, Full Time

• Strengthen connections between Cleveland Clinic providers and primary care practices across the network
• Provide resources and support to promote coordinated, high-quality care
• Support utilization of Cleveland Clinic network providers and use the EMR for timely communication and care coordination
• Partner with patients, care partners, and primary care practices to support positive outcomes
• Build practice capacity for performance improvement initiatives and advance improvements in care delivery
• Serve as subject matter expert for the Navigation team
• Implement processes to guide patients to appropriate resources and support services
• Identify, evaluate, and resolve patient concerns
• Participate in multidisciplinary team projects
• Maintain departmental workflow and communications with internal and external stakeholders
• Develop communication standards and relationships with internal providers across the Cleveland Clinic network
• Complete data tracking and collection to identify statistics, opportunities, and trends
• Review, facilitate, and complete care gap closures for assigned patient populations
• Assess and provide feedback to practices regarding organizational, clinical, and business functions
• Use practice-level and physician data to drive change for value-based operations
• Coordinate and implement distribution of new clinical functionality practices
• Travel to provider offices and schedule group user training when necessary
• Document and diagram existing workflows; identify improvement opportunities and design and implement improvements with practice and Navigation Leadership teams
• Train practice staff to use data effectively for performance improvement
• Promote best-practice sharing related to performance measures
• Build team orientation and promote effective communication among practice staff
• Create a practice culture receptive to change
• Perform other duties as assigned

Population Health Navigator III – Post-Acute Care

• Address patient and durable power of attorney (DPOA) inquiries via telephone
• Respond to patient or caregiver messages received via the Curana Patient Portal
• Assist patients with scheduling follow-up appointments with Curana Providers or specialists
• Manage electronic health records (EHR) and ensure accurate and up-to-date patient records
• Coordinate documents needed for provider review or signature
• Facilitate provider orders and escalate findings
• Maintain patient rosters for patients enrolled in APCM and GUIDE
• Support provider scheduling
• Assist with prior authorizations
• Obtain patient records and diagnostic test results
• Answer and manage incoming calls professionally and courteously
• Collaborate with the Curana Interdisciplinary Care Team to ensure seamless communication within the health network
• Perform other duties as assigned

• Navigate the cancer-care journey, including diagnostic testing, specialist consultations, treatment planning, surgery, systemic therapies, radiation, recovery, follow-up, and survivorship
• Prepare for medical appointments by organizing information and developing prioritized questions for specialists
• Organize physician recommendations, identify unresolved questions, and translate agreed plans into next steps
• Coordinate information across oncology, breast surgery, cardiology/cardio-oncology, primary care, nutrition, and other specialists with client authorization
• Maintain a care plan tracking appointments, testing, recommendations, medications, pending decisions, questions, and follow-up actions
• Help the client understand general medical terminology and treatment pathways and identify questions for physicians
• Facilitate second opinions and additional specialist consultations
• Provide patient advocacy and communicate the client’s priorities, concerns, and questions to the healthcare team
• Support physician-approved priorities involving nutrition, hydration, medication adherence, sleep, movement, recovery, stress management, and other health behaviors
• Provide calm, compassionate support and refer medical, nutritional, or psychological issues to appropriate licensed professionals
• Support recommendations from physicians and/or a registered dietitian related to calories, protein, weight, muscle preservation, hydration, eating barriers, physical activity, sleep, recovery, and stress management
• Participate in or support important medical appointments when requested and authorized
• Maintain confidentiality of sensitive personal and medical information

Oncology Care Navigator

• Develop, assess, and coordinate care management activities based on member needs
• Develop or contribute to personalized care plans/service plans
• Educate members and families/caregivers on services, benefit options, care options, referrals, healthcare benefits, and provider instructions
• Evaluate member needs, barriers to care, available resources, and recommend/facilitate plans
• Identify providers, specialists, and community resources needed for care
• Provide psychosocial and resource support for employment, education, housing, food, participant direction, independent living, justice, and foster care needs
• Coordinate between members/families/caregivers and care provider teams to ensure timely access to care and services
• Monitor progress toward care plan goals and member status or changes in condition
• Collaborate with healthcare providers on care plan revisions and refer members for further care management evaluation
• Collect, document, and maintain member information and care management activities for regulatory compliance
• Perform on-site visits as appropriate to assess member needs and collaborate with providers/resources
• Perform other assigned duties and comply with policies and standards