Overview The RN Patient Navigator plays a key role in promoting high quality, patient-centered care by coordinating transitional care, preventive services, and chronic disease management. This position focuses on guiding patients through the healthcare system, ensuring timely follow-up, improving health outcomes, and reducing avoidable hospital readmissions. The RN Patient Navigator will support primary care teams by facilitating access to care, enhancing communication between providers, and engaging patients through telehealth and community-based outreach Job Details Key Responsibilities: Transition of Care Coordination + Assist in scheduling timely Transition of Care (TOC) visits for: + Unattached Emergency Department (ED) and hospital discharges. + Established patients discharged from hospitals to reduce readmission risk and prevent suboptimal outcomes. + Collaborate with hospital discharge planners and primary care providers to ensure continuity of care. Medicare Annual Wellness Visit (AWV) Management + Manage and maintain databases of Medicare patients eligible for AWVs. + Conduct telemedicine AWVs, including: + Screening tools (PHQ-9, Social Determinants of Health, and Cognitive Risk Assessment). + Durable Medical Equipment (DME) assessments and ordering. + Medication reconciliation and prior authorizations. + Obtaining medical records, labs, and imaging pre-visit. Chronic Disease & High-Risk Patient Management + Act as a point of contact and care coach for high-risk patients. + Conduct proactive care coordination, including: + Appointment scheduling, referrals, specialist/imaging coordination. + Community resource navigation and chronic condition support (e.g., CHF, diabetes, hypertension). + Monitor patients via telecommunication for signs of decompensation and escalate care when needed. + Support medication adherence and provide disease-specific education. Care Gap Closure & Quality Improvement + Assist with outreach initiatives to close preventive and chronic care gaps. + Maintain and manage care management registries to identify and monitor patients needing follow-up. + Document interventions and outcomes in the electronic health record (EHR) and report metrics as required. Physician Support & Administrative Duties Support providers by: + Managing inboxes for abnormal labs and initiating follow-up per physician directive. + Coordinating care team communications and assisting with patient queries and care instructions. Qualifications: + Current RN license in the state of New York + Minimum 2 years of experience in care coordination, population health, or primary care preferred. + Experience with Medicare Annual Wellness Visits, transitional care, and chronic care management. + Strong working knowledge of electronic health records (EHR) and care management tools. + Excellent interpersonal, organizational, and critical thinking skills. + Ability to work independently and as part of a multidisciplinary team. + Knowledge of quality metrics, care gaps, and risk adjustment coding is a plus. + Bilingual – Spanish speaking a plus Preferred Skills: + Experience in telehealth platforms and patient engagement via remote technology. + Familiarity with PHQ-9, SDOH screenings, and DME ordering processes. + Understanding of healthcare resources within the community setting. Salary Range USD $52.14 - USD $71.51 /Hr. This range serves as a good faith estimate and actual pay will encompass a number of factors, including a candidate’s qualifications, skills, competencies and experience. The salary range or rate listed does not include any bonuses/incentive, differential pay or other forms of compensation that may be applicable to this job and it does not include the value of benefits. At Catholic Health, we believe in a people-first approach. In addition to the estimated base pay provided, Catholic Health offers generous benefits packages, generous tuition assistance, a defined benefit pension plan, and a culture that supports professional and educational growth.