Care Navigator / Chronic Care Management - local candidates around Reston

Job Summary

Join our growing team of Care Navigators! We are looking for dedicated professionals to provide continuous care coordination, supporting chronically ill patients through Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) Programs. This role combines both administrative and clinical responsibilities in a dynamic, fast-paced environment.

This is a full-time, position working Monday through Friday.

Please note that you must be available on-site.

Job Responsibilities:

• Conduct regular phone calls with patients to ensure their vitals are monitored between office visits. Please note that you are spending 7-8 hours on the phone daily.
• Respond to biometric readings quickly, such as high blood pressure or high blood sugar readings, during regular business hours to support the patient's primary care provider in managing the patient's chronic condition(s).
• Identify SDoH, gaps in care, and eligibility for assistance or other referral services for patients in need. You coordinate with Netrin staff, and other community programs and resources to address these gaps effectively.
• Create and/or revise personalized care plans for each patient you call on, in coordination with the providers you support.
• Provide non face to face assessments of patients with 2 or more chronic conditions and communicate any concerns to the provider and care team as appropriate.
• Provide education to patients with chronic conditions on the importance of medication compliance, diet, exercise etc and ensure patients are following instructions,
• Documents all patient calls in the EHR and upon enrollment,
• Assist in obtaining any outside records from specialists for the Primary Care Physician before upcoming appointments.
• Make sure the patient is following any recommendations made by specialists.
• Meet regularly with the providers to review caseload and identify any workflow issues.
• Actively communicate with staff nurses, providers and practice managers on any issues with patients enrolled in the RPM/CCM Programs.

Skills:

• Demonstrate ability to work collaboratively and optimally with patients with serious health conditions, as well as with multidisciplinary teams of providers and caregivers.
• Demonstrate a general understanding of managed care principles, goals, and targets
• Be highly self-motivated, organized and able to work independently
• Knowledge of compliant billing protocols, and Medicare CCM service programs
• HIPAA knowledge and understanding Demonstrated strength in documenting within an EHR
• Ability to effectively problem-solve when faced with clinical decision making challenges

Requirements:

• Fluent in English. Spanish is a plus.
• Excellent communication and customer service skills - You will be the voice of Netrin Health on the frontline speaking with the patients. You need to be highly professional on the phone, able to maintain a compassionate and engaging tone , quick thinking when responding to patient questions and needs, with strong critical thinking skills to ask appropriate follow-up questions.
• A home office set up that will allow you to maintain confidentiality when speaking with patients. Fast and reliable internet with internet speed equal to or greater than 25mbps. (We will provide you with a company laptop and the software you need to make patient calls)
• Familiarity with Microsoft Office, GoogleSuite products and comfortable learning new platforms quickly.
• Experience serving geriatric population, multiple EMR/EHR systems and motivational interviewing are plus.

Medical Specialties: Geriatrics, Home Health, Internal Medicine, Primary Care

Netrin Health is population health management services organization that offers high quality healthcare solutions to Accountable Care Organizations (ACO's), Clinically Integrated Networks (CIN), Health Systems and Physician practices from several locations in Virginia, Maryland, District of Columbia, Delaware, Pennsylvania, New Jersey, South Carolina and West-Virginia.

Netrin collaborates with independent practices, health systems and employer health plans to optimize clinical outcomes, improve patient experiences and reward providers for delivering high-value care in both in-person and virtual settings.

Job Type: Full-time

Pay: $18.00 - $23.00 per hour

Expected hours: 40 per week

Benefits:

• Health insurance
• Paid time off

Medical Specialty:

• Primary Care

Schedule:

• 8 hour shift
• Monday to Friday

Application Question(s):

• This position requires spending 7-8 hours daily on the phone, providing care coordination and patient education. Describe your experience or comfort level with spending most of your workday on the phone. How do you stay focused and maintain a compassionate tone during your working hours?
• You are speaking with a patient who is upset and confused about their care plan. How would you handle the conversation to clarify their concerns, provide reassurance, and ensure they feel valued and supported? Please describe your approach or share an example from your experience.

Ability to Commute:

• Reston, VA 20190 (Required)

Ability to Relocate:

• Reston, VA 20190: Relocate before starting work (Preferred)

Work Location: In person

Salary : $18 - $23