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Patient Care Navigator (Bronx Location)


Hope Care Management-Bronx location

Reports To:

Program Director

Major Functions:

 Under general supervision, the Patient Care Navigator assists the Care Coordinator Supervisor and Care Manager in the provision of care management activities to support clients and their families in accessing needed services.  The Patient Care Navigator is primarily responsible for addressing member needs (i.e. appointment monitoring, event notifications), providing care plan updates and conducting outreach to members in between visits. Patient Care Navigators are the cornerstone of care management teams, must understand how to access services, communicate effectively and build strong relationships with members. 


Specific Duties and Responsibilities:


  • Conducts agency visits to client's providers.
  • Maintains a separate and individual caseload as assigned by Care Manager and/or Care Coordinator Supervisor.
  • Utilizes approved Health Home assessment tools and Health Information Technology (HIT) to complete initial and annual assessments and to develop an appropriate care plan of service needs.
  • Completes an accurate monthly HML assessment for each assigned member.
  • Provides referrals, develops linkages and follows up on client services including timely documentation in all Electronic Medical Records for corresponding Health Homes.
  • Uses health Information Technology (HIT) dashboards to link services and communicate among care management team, providers, members and their families/caregivers.
  • Conducts member outreach and engagement activities to designated and potential Health Home members, including face-to-face, mail, electronic and telephone contact.
  • Ensures that services provided to each member of his/her caseload meets core values of care management services as set forth in federal guidelines of Affordable Care Act.
  • Assists members in accessing health care and social service systems including arranging for transportation, scheduling and accompanying member to appointments.
  • Helps members in identifying available community-based resources and actively manage appropriate referrals, access, engagement, follow-up and coordination of services.
  • Assists with coordinating members access to individual and family supports and resources including resources relating to housing, management of mental illness, substance abuse disorders, smoking cessation, diabetes, asthma, hypertension, self-help/recovery resources and other services based on individual needs and preferences.
  • Helps members with managing daily routines related to healthcare and incorporating members’ strengths and identifying barriers.
  • Assists with conducting outreach and engagement activities that support continuity of care including reengaging members in care if they miss appointments and/or don’t follow-up on treatment.
  • Performs other duties as requested.



  • Bachelor's Degree in Human Services or related field, required.
  • Two years of experience in providing direct services to people with serious mental illness, developmental disabilities, or substance use disorders or linking these individuals to a broad range of services essential to successful living in a community setting (e.g. medical, psychiatric, social, educational, legal, housing and financial services
  • Prior Health Home experience, preferred.
  • Bi-lingual Spanish preferred.


If you are interested in this position, please submit your resume with a cover letter to