Care Navigation & Reporting Coordinator (RN/LPN)

Position overview

The Care Navigation Coordinator is the patient-facing operational backbone of a two-year, grant-funded Encounter Telehealth program. The Coordinator owns the full continuum of care navigation — from first contact through closed-loop referral — for individuals with chronic conditions at rural partner facilities, serving as the primary navigation contact for six partner facilities in year one and six additional facilities in year two.

This role also carries the community health education function: delivering structured chronic disease self-management workshops remotely via telehealth and expanding behavioral health access to the broader rural community. All care navigation and education is delivered remotely — the Coordinator works directly with patients and their families by phone and telehealth, with no requirement for in-person facility visits. The facility’s only ongoing obligation is patient referral and minimal session facilitation (bringing a device to the patient).

This is a builder role requiring clinical depth, disciplined remote coordination, and the ability to earn trust from patients and facility contacts without being physically present.

Core responsibilities

A. Care Navigation & Patient Engagement

Primary navigation contact. *Serve as the main point of contact for enrolled participants across an assigned panel of rural partner facilities (skilled nursing facilities, assisted living communities, critical access hospitals, rural health clinics, and FQHCs), managing appointment coordination, medication reconciliation support, insurance literacy, disease management education, and community resource linkage through a closed-loop referral tracking system. Enrollment. *Onboard participants into the chronic disease behavioral health management program; enrollment targets per the final grant workplan. Transition-of-care outreach. *Conduct follow-up to reduce gaps between discharge, referral, and behavioral health engagement.

Site relationships. *Build and maintain trust-based relationships with DONs, Social Services Directors, and nursing leads at assigned partner sites — the consistent human face of Encounter’s program at each location. This is a remote position. Occasional travel may be required.

Telehealth coordination. *Coordinate with facility-designated telehealth contacts (SSDs or nursing designees) to support smooth session facilitation and equipment use, working alongside the Telehealth Technology Implementation Specialist. Crisis escalation. *Implement crisis escalation protocols when PHQ-9 or GAD-7 screening flags safety concerns, operating within the Coordinator’s licensure scope of practice and connecting patients to appropriate clinical resources. Assessment administration. *Administer SDOH-related assessments to participants in the care navigation program.

B. Community Education & Outreach

Workshop delivery. *Plan and deliver structured chronic disease self-management workshops in 6-week cycles addressing behavioral health barriers to medication adherence, care plan follow-through, and self-management; cycle and participant targets per the final grant workplan. Community access. *Expand behavioral health access beyond facility residents to facility staff families and broader rural community members, building and operationalizing community referral pathways. Community partnerships. *Develop and maintain relationships with rural primary care providers, schools, Area Agencies on Aging, transportation organizations, and food access resources across assigned service areas.

Individual & group education. *Deliver sessions emphasizing the connection between mental health and chronic disease outcomes (diabetes, CVD, COPD). Screening support. *Assist with PHQ-9 and GAD-7 screening protocol implementation and provide participant education on behavioral health screening and referral pathways.

C. Telehealth Session & Site Coordination

Session logistics. *Manage participant scheduling and session logistics across assigned sites, ensuring PMHNP-to-facility provider continuity. Facility coordination. *Serve as the day-to-day operational contact for facility telehealth contacts on scheduling and session workflow; escalate equipment and technical issues to the Telehealth Technology Implementation Specialist.

D. Tracking & Reporting Support

Data entry. *Maintain enrollment, screening, and navigation activity logs in Tebra and partner EHR systems, ensuring accuracy for quarterly grant reporting. Activity tracking. *Track workshop attendance, referral completion, appointment adherence, and closed-loop referral outcomes at the participant level. Reporting handoff. *Submit timely, accurate data to the program’s quality and reporting function to support quarterly grant reporting and compliance with applicable grant requirements. Documentation. *Document all participant interactions, navigation activities, and program milestones in accordance with HIPAA requirements.

About encounter telehealth

Encounter Telehealth is a behavioral healthcare provider headquartered in Omaha, Nebraska, specializing in geriatric psychiatry and rural mental health access. We serve nearly 200 partner facilities across multiple states with CMS-verified outcomes:

• 7.3-point *reduction in rehospitalization rates
• 1.5% *depression symptoms vs. 11.4% nationally
• Half *the national average for antipsychotic use

We’re aggressively growing and looking for inquisitive self-starters who want to build something that matters — and who understand that good data and good care are two sides of the same coin.

Pay: $58,000.00 - $60,000.00 per year

Benefits

• 401(k)
• Dental insurance
• Health insurance
• Paid sick time
• Paid time off

Application Question(s)

• Briefly describe your experience with clinical data collection, outcomes tracking, or grant/regulatory reporting. Please include the type of program, your role, and what reporting systems or EMRs you used.

Experience

• Care coordination, case management, or patient navigation: 3 years (Required)

License/

Certification

• RN, LPN (Required)

Work Location: Remote