SNF at Home Navigator

• Put Patients First
• Empower Entrepreneurial Provider and Care Teams
• Operate with Integrity & Excellence
• Be Innovative
• Work As One Team

Key Responsibilities

• Contact patients and family members to discuss SNF at Home program options, eligibility requirements, and enrollment opportunities.
• Educate patients and caregivers on the benefits, expectations, services, and logistics of receiving skilled nursing-level care in the home setting.
• Serve as a compassionate and professional point of contact for patients and families throughout the transition process.
• Support patient and caregiver understanding of care plans, program services, and next steps related to home-based care.
• Conduct outreach and follow-up communications to promote patient engagement and successful program participation.
• Navigate sensitive conversations with patients and families while maintaining a patient-centered approach.

• Coordinate outreach and transition activities for patients being discharged directly into a SNF at Home program or transitioning from a traditional SNF setting to home-based care.
• Collaborate with clinical teams, case managers, discharge planners, SNF staff, and Home Care Advantage team members to support seamless patient transitions.
• Facilitate communication between patients, families, providers, facilities, and internal stakeholders throughout the transition process.
• Assist with scheduling activities, transition planning, follow-up communication, and enrollment-related coordination.
• Identify barriers to successful transitions and escalate concerns to the appropriate team members.
• Support continuity of care through effective coordination and timely communication.

• Conduct in-person visits at hospitals and Skilled Nursing Facilities throughout Rhode Island to meet with patients, caregivers, facility staff, and care teams.
• Build and maintain productive working relationships with discharge planners, case managers, SNF personnel, and healthcare providers.
• Represent the organization professionally during onsite meetings, educational discussions, and care transition activities.
• Support facility and provider engagement efforts that enhance awareness and adoption of SNF at Home services.
• Participate in meetings and outreach activities that support program growth and patient access.

• Document patient interactions, outreach efforts, transition activities, and coordination notes accurately and timely.
• Maintain confidentiality and compliance with HIPAA requirements, organizational policies, and applicable healthcare regulations.
• Track outreach activities, enrollment progress, and transition outcomes using approved systems and tools.
• Support reporting, operational workflows, and administrative processes related to program performance and patient engagement.
• Participate in team meetings, training sessions, and organizational initiatives as required.
• Perform other duties and special projects as assigned.

Skills, Knowledge & Expertise

• Associate's degree in Nursing required.
• Bachelor's degree in Nursing, Healthcare Administration, Public Health, or a related field preferred.

• Registered Nurse (RN) required.
• Experience in healthcare administration, care coordination, case management, discharge planning, patient navigation, or customer service within a healthcare environment preferred.
• Experience working with patients and families during transitions of care preferred.
• Familiarity with Skilled Nursing Facilities (SNFs), post-acute care, home health, or home-based care programs preferred.
• Experience collaborating with hospitals, providers, case managers, or care coordination teams preferred.

• Active Registered Nurse (RN) license required.
• Valid driver's license and reliable transportation required.

• Strong knowledge of care coordination, patient engagement, transition of care, and healthcare service delivery models.
• Excellent verbal, written, and interpersonal communication skills.
• Ability to effectively communicate with patients, caregivers, providers, facility staff, and healthcare professionals.
• Strong organizational and time management skills with the ability to manage multiple priorities independently.
• Ability to work both remotely and independently in a field-based environment.
• Strong problem-solving skills and ability to navigate complex patient situations with professionalism and empathy.
• Proficiency with Microsoft Office applications and basic computer systems.
• Ability to maintain accurate documentation and manage confidential information appropriately.
• High degree of professionalism, accountability, integrity, and attention to detail.
• Commitment to providing exceptional patient and family experiences.

• Experience supporting post-acute care, discharge planning, care transitions, or home-based care programs.
• Experience working with Skilled Nursing Facilities, hospitals, home health agencies, or value-based care organizations.
• Experience in patient outreach, patient education, enrollment support, or care navigation roles.
• Experience collaborating with interdisciplinary care teams and community healthcare partners.
• Familiarity with healthcare documentation systems and care coordination platforms.

Benefits

• This position is based in Rhode Island and supports SNF at Home program operations throughout the state.
• The role follows a hybrid work model and requires a combination of remote work and field-based travel.
• Travel throughout Rhode Island is required to support hospitals, Skilled Nursing Facilities, patient visits, and care transition activities.
• The employee must be able to attend meetings in person or virtually based on business needs.
• Work requires regular use of computers, telephones, mobile devices, electronic documentation systems, and virtual communication tools.
• The employee must maintain reliable transportation and the ability to travel independently throughout the assigned territory.
• The employee must comply with organizational policies and procedures regarding patient privacy, protected health information, HIPAA requirements, and all applicable federal and state regulations.