Care Navigator

About the Role

We’re looking for an experienced Care Navigator to join our virtual program serving patients in Pennsylvania, New Jersey, New York, and Delaware (with more to come!). This is substantive case management work — you’ll carry a real caseload, build individualized care plans, and see needs through to resolution. Most patients come to us with more than one open need at a time, and the barriers they face are specific: a particular insurance rule, a program with a waitlist, a resource that exists in one county and not another.

The program primarily serves patients in our Centers of Excellence (CoE) in Pennsylvania, and. navigation happens virtually — primarily over SMS, with phone, and zoom as needed. You’ll work closely with a clinical team who are active in the same patient records, and you’ll document your work as you go so the whole team stays informed.

This is a good fit for someone who is comfortable building trust with patients through consistent, purposeful contact over time — and who understands that in a virtual care setting, good documentation is part of good care.

What You’ll Do

Care Navigation & Case Management

• Manage an active caseload of patients developing and maintaining individualized care plans; providing consistent emotional support and encouragement, recognizing that practical barriers and emotional ones often show up together - especially for patients navigating recovery
• Reach patients by SMS and phone to assess needs, clarify barriers, and keep cases moving — building rapport through consistency rather than long sessions
• Research targeted resources for each patient based on their specific situation — insurance status, location, income, and the actual barrier they’re facing
• Follow cases through to confirmed resolution; average time to close a need is around 44 days
• Escalate the most complex cases for specialist support, and facilitate step-down back to your caseload when appropriate

Resource Coordination

• Maintain current knowledge of resources, programs, and eligibility rules across PA, NJ, NY, and DE
• Navigate public benefit systems including Medicaid, SNAP, transportation assistance, housing programs, and behavioral health services
• Build relationships with community-based organizations and providers in the region
• Provide warm handoffs, direct scheduling, or guided next steps based on what each patient needs

Documentation & Collaboration

• Document your work in the EMR as you go — activity, resource decisions, status changes, and next steps — so the clinical team always has the full picture
• Collaborate with providers through shared patient records, escalating clinical concerns, safety issues, and urgent needs to the appropriate clinical team member promptly and with the right context
• Participate in team meetings and case reviews

Qualifications

Required

• 2+ years in care navigation, case management, or community health — with meaningful experience delivered virtually or over the phone
• Direct experience with SDOH navigation — housing, transportation, food access, behavioral health, benefits enrollment
• Working knowledge of community resources, programs, and systems in PA, NJ, NY, and/or DE
• Proficient and comfortable using EMR or care management platforms as primary daily tools, with strong overall tech savviness
• Strong written communication skills — you’re clear and professional with patients over text and phone
• Ability to independently manage a caseload, prioritize across competing needs, and track cases through to resolution
• High school diploma or GED required; associate’s or bachelor’s in social work, public health, or human services preferred
• Demonstrated ability to work with diverse patient populations with cultural humility — adapting communication and approaches to align with each patient's background, values, and circumstances

Strongly Preferred

• Experience in a Center of Excellence or specialty care program serving patients with complex, co-occurring needs
• Familiarity with Medicaid populations and managed care requirements in NJ or PA
• Experience navigating drug & alcohol, psychiatric care, or specialty behavioral health resources
• CHW certification or equivalent credential
• Familiarity with trauma-informed care principles, harm reduction philosophy and motivational interviewing as frameworks that shape how you listen, communicate, and engage

Who Thrives in This Role

Our strongest navigators are people who get real satisfaction from moving a case forward — who can hold a patient’s situation in mind, stay organized across a full caseload, and keep going when the obvious resource doesn’t pan out. They build genuine relationships with patients over SMS and phone, and they understand that in a virtual setting, how you document your work is how care continues when you’re not there. They meet patients where they are—providing judgment-free support, honor individual recovery paths, and respect each person's unique timeline for progress.

This role is a strong fit if you thrive in a structured environment with clear accountability, and you find meaning in the problem-solving work of navigation — not just the connecting. It may not be the right fit if you’re looking for a role with long, open-ended patient sessions, flexible self-directed pacing, or in-person community presence. This position is fully remote and SMS-first, with a defined caseload and workflow.

Work Environment

• Fully remote — reliable internet and a private workspace required
• All patient contact via SMS, phone and zoom — no in-person visits
• EMR-based workflow; comfort with digital tools is essential
• Collaborative team across PA and NJ with regular virtual team touchpoints

Our Benefits Include:

• Competitive medical, vision, and health insurance (many plans are fully covered for the employee!)
• Start with 20 days (4 weeks) of PTO, increasing to 5 weeks after 2 years and 6 weeks after 5 years of tenure
• 10 company holidays
• Work From Home Stipend
• 401k Contribution Platform
• Additional benefits offered through our benefits provider such as life insurance, short and long term disability, financial wellness, virtual primary care, among others!

Interested in learning more about Ophelia and this role? Apply to work with us!