Landmark Health

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Patient Care Navigator

Patient Care Navigator

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Clinical Delivery Field
Regular Full-Time
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Job ID 

More information about this job


Do you want to make a difference in healthcare?

Landmark Health was created to transform how healthcare is delivered to the most medically vulnerable members in our community.  Our medical group provides home-based medical care to chronically ill patients, many of whom are ill-equipped to navigate our overwhelming healthcare system.  

Because many of our patients are frail and elderly, we deliver care primarily in their home. Our Program is offered to eligible patients at no incremental financial cost. We are not a fee-for-service practice; we benefit economically only if we deliver high-quality patient outcomes and satisfaction. Our clinical teams spend quality time caring for a smaller number of high-risk patients, granting patients the respect, compassion and care they deserve.

At Landmark, our interdisciplinary teams collaboratively manage our complex patient panels. These teams are led by Physicians, Nurse Practitioners, and Physician Assistants, with supporting care provided by RN Nurse Care Managers, Social Workers, Pharmacists, Behavioral Health, Care Coordinators and other team members.


The Ambassador/ Care Coordinator Hybrid role is a pivotal member of the Landmark Interdisciplinary Team.

As an Ambassador (50%), you will actively engage with patients both in the home and over the phone. You will use your critical thinking and communication skills to build lasting and impactful relationships with patients and caregivers, and you will use your compassion and empathy to earn their trust. You will help patients understand the value of the Landmark Program, and how best to use its services.  You will conduct structured surveys with patients over the phone or in the home to collect clinical and psychosocial data. You will partner with Landmark Providers and Interdisciplinary Team members to drive improvement in patient outcomes, and you will be expected to contribute valuable insights to weekly interdisciplinary team discussions.

As a Care Coordinator (50)% you will use your organizational skills and patient-first mentality to assist patients with care coordination needs, conduct telephonic surveys to collect data, and support patients in scheduling home visits. You will also support Landmark Physicians, Advance Practice Providers, and RN Nurse Care Managers with important operational and clinical tasks.



  • Patient visits - Delivering value to lower acuity patients to ensure that Landmark is a trusted place to turn in an urgent medical situation by establishing rapport and strong relationships while visiting patients at their location.
  • Patient phone calls (Outbound & Inbound) - For all new patients, gather information using the Human Factor Survey (HFS). Call PCPs/others to assist with care coordination activities. Assist lower acuity patients telephonically when appropriate.  Manage Reminder Calls.   Field incoming administrative questions and escalate any clinical questions to the Clinical Supervisor or NCMs.
  • Schedule Optimization - Optimize provider calendars (e.g. reorder visits, backfill empty slots) to minimize drive time and maximize patient-facing visit time.
  • Manage medical records and documents (Outbound & Inbound) – Processing incoming paperwork, mail documents; process requests for medical records for POD, review e-Consents for finalized processing.    
  • Team Huddle and IDT – Join discussion daily with your POD and weekly with IDT to take point on follow ups as needed.
  • Other duties as may be assigned.


  • High school diploma or equivalent required. BA strongly preferred.
  • Experience as a Medical Assistant, Certified Nursing Assistant, Pharmacy Tech, or other clinical or administrative role in a health care setting, preferred but not required.
  • Experience with escalated customer service issue resolution and experience with following triage protocol a plus.
  • Critical thinking skills and flexibility are required for success in role.
  • Knowledge of MS Office products; typing speed of 40+ WPM preferred.
  • Proficiency in Excel.

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