The Regional Patient Navigator plays a critical role in supporting patients as they transition from skilled nursing facilities (SNFs) to appropriate post-discharge health services at home. This individual works onsite within SNFs to identify patient needs, collaborate with interdisciplinary care teams, and facilitate smooth transitions back to the patient’s home that best supports recovery, safety, and continuity of care.
This role is ideal for a self-motivated professional with experience in case management, care coordination, or social work who is comfortable working independently in the field and building trusted relationships with facility staff, patients, and families.
Responsibilities
Establish a consistent presence within assigned skilled nursing facilities to support post-discharge planning and care transitions
Identify patients who may benefit from post-acute health services through collaboration with nursing, social services, and discharge planning teams
Educate patients and families on available care options and support informed decision-making for post-discharge services
Coordinate referrals and facilitate timely transitions to appropriate post-acute providers
Serve as a liaison between SNF staff and post-acute care partners to ensure clear communication and continuity of care
Document patient interactions, referrals, and outcomes in accordance with organizational and regulatory standards
Build and maintain strong professional relationships within facilities through reliability, responsiveness, and ethical conduct
Travel independently between assigned facilities within the designated territory
Education & Experience
Bachelor’s degree required; Master’s degree (MSW, MHA, or related field) preferred
Background in case management, care coordination, social work, patient advocacy, or related healthcare roles
Clinical licensure not required
Knowledge, Skills and Abilities
Strong understanding of care transitions, discharge planning processes, and patient support needs
Excellent interpersonal, communication, and organizational skills
Ability to work autonomously, manage time effectively, and prioritize in a dynamic environment
Comfortable engaging with patients, families, and multidisciplinary healthcare teams
Self-starter with strong initiative and follow-through
Professional, compassionate, and patient-centered approach
Adaptable and comfortable working across diverse facility environments
Relationship-oriented with a collaborative mindset
Physical Requirements
Long periods of sitting at computer, using telephone, typing
Long periods of driving, walking, and standing in both home and healthcare facility environments.
Working Conditions
Position requires regular local travel to skilled nursing facilities
Must be willing and able to travel up to 1.5 hours driving distance within assigned territory
Field-based role with minimal direct supervision
Numbers & Facts
Location
Erie, Pennsylvania
Skills
ADPunmatched
Acute Careunmatched
Case Managementunmatched
Communication Skillsunmatched
Community and Social Servicesunmatched
Cross-Functionalunmatched
Decision Supportunmatched
Discharge Plansunmatched
Employee Relationsunmatched
Establish Prioritiesunmatched
Follow Throughunmatched
Healthcareunmatched
Home Careunmatched
Interpersonal Skillsunmatched
Needs Assessmentunmatched
Nursingunmatched
Organizational Skillsunmatched
Patient Careunmatched
Patient Educationunmatched
Regulationsunmatched
Social Workunmatched
Team Playerunmatched
Time Managementunmatched
Typingunmatched
Willing to Travelunmatched
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