Paient Navigator, MSW, BSW or CHW

Description

Sierra Healthcare – Care Coordination / Case Management

Job Overview

The Sierra Cares Navigator plays a key role in ensuring uninsured and high-risk patients experience a smooth transition from hospital to home health, hospice, or palliative care services. This role works closely with hospital case managers, discharge planners, and Sierra clinical teams to coordinate referrals, remove barriers to care, and ensure services begin quickly and efficiently.

The Navigator maintains the Sierra Cares program census, tracks referral flow, and serves as a trusted liaison between hospitals and Sierra Healthcare to improve patient outcomes and reduce delays in care transitions.

Key Responsibilities

• Build and maintain a real-time Sierra Cares census tracking referrals, admissions, eligibility, start-of-care dates, payer status, and outcomes.

• Monitor and report referral pipeline movement from referral to intake, eligibility, scheduling, and start of care.

• Ensure documentation accuracy and completeness for internal reporting and hospital updates.

• Coordinate referrals through centralized intake and support rapid service initiation (often within 24 hours).

• Verify program eligibility and gather documentation with hospital and Sierra teams.

• Serve as a consistent point of contact for patients, families, and hospital staff.

• Act as liaison to hospital case managers and discharge planners.

• Promote the Sierra Cares program through rounding, huddles, and education sessions.

• Track program metrics such as patients served, readmissions, satisfaction, and timeliness.

• Identify trends or barriers in referral processes and recommend workflow improvements.

• Provide patient and family education and connect patients with community resources

Requirements

Required Qualifications

• • Experience in healthcare case management or care coordination.
• • Experience with hospital discharge planning, home health, hospice, or post-acute care preferred.
• • Strong communication and collaboration skills with interdisciplinary clinical teams.
• • Ability to manage time-sensitive referrals and multiple priorities. Preferred Qualifications
• • MSW, CHW or experience in care transitions or resource navigation.
• • Bilingual abilities (where applicable).
• • Experience tracking outcomes, maintaining reports, or managing referral dashboards.

Key Skills

• • Strong organizational and referral management skills
• • Relationship building with hospital partners
• • Data tracking and reporting
• • EMR documentation and spreadsheet tracking
• • Problem-solving and removing barriers to care access