Job Title: Care Navigator & Medical Assistant Job Location: Helena, MT Applicants must be comfortable working 7a-4p MST Company Description: Greater Good Health is a fast-growing organization delivering care to older adults in access starved communities. Our innovative model is led by Nurse Practitioners and focused on outcomes, not volume—meaning we prioritize quality over quantity, spend more time with our patients, and are accountable for their health and well-being. Whether through our own senior-focused primary care clinics or our suite of integrated clinical solutions for health plans and provider groups, we are making value-based care more accessible and more effective. We help reduce avoidable healthcare costs, improve clinical outcomes, and create a best-in-class patient experience. If you're passionate about transforming healthcare and delivering meaningful care to those who need it most, Greater Good Health offers a purpose-driven, collaborative, and supportive environment where your work can make a lasting impact. Typical Duties: - Patient Outreach & Engagement - Conduct proactive outreach to schedule patient home, telehealth, and in-clinic visits to complete Annual Wellness Visits (AWVs), ensuring patients receive timely preventative care and individualized care plans. - Accept inbound calls from patients to schedule AWVs and address care-related questions or concerns. - Connect with the geriatric population to build trusting, long-term relationships — making patients feel calm, comfortable, and heard throughout their care experience. - Identify and address barriers to engagement, including transportation, language, health literacy, financial hardship, and other social and environmental factors. - Outreach to patients to complete key preventative screenings (colon cancer, mammograms, diabetic retina scans, HbA1c, and more), documenting outreach and establishing follow-through plans. - Care Coordination & Panel Management - Partner closely with assigned GGH Nurse Practitioners (NPs) to co-manage their patient panel, serving as the day-to-day coordination hub for scheduling, care follow-through, and patient communication. - Build and optimize driving routes for GGH Nurse Practitioners completing home visits, maximizing time spent with patients. - Coordinate patient cancellations, reschedules, and add-on visits with the NP to ensure continuity of care and efficient schedule management. - Retrieve and reconcile medical records from outside providers, hospitals, health systems, and community organizations to ensure the care team has a complete and current view of each patient’s health history. - Manage patients post-discharge from hospital or skilled nursing facility settings, coordinating timely follow-up visits and facilitating care plan transitions to reduce readmission risk. - Follow up with patients on outstanding provider orders — including lab work, imaging, specialist referrals, and durable medical equipment — ensuring completion and routing results back to the care team. - Coordinate referrals and activities for high-risk programs, facilitating smooth transitions between care settings and service providers. - Support the care team in identifying and closing quality gaps, including HEDIS measures and chronic disease management needs. - Compliance & Documentation - Handle protected health information (PHI) with discretion, adhering to HIPAA standards and GGH privacy policies at all times. - Maintain timely, accurate, and thorough documentation of all patient interactions, outreach attempts, care coordination activities, and follow-up plans. - Collaboration & Program Development - Build strong, positive working relationships with GGH Nurse Practitioners and the Patient Outreach Team, and maintain professional communications with client partners and the broader care team. - Participate in interdisciplinary care team meetings, contributing patient updates and coordinating action steps across team members. - Maintain collaborative relationships with clinicians and the leadership team to support the development of new programs aimed at improving patient engagement, care coordination, and health outcomes. - Other duties as assigned. Medical Assistant Duties - future state: - Clinic opening TBD, but will include normal primary care MA duties from rooming, vitals, etc. Key Success Outcomes: - Completing 50–100 outbound calls per day. - Achieving conversion rate expectations for AWV scheduling and preventative care outreach. - Successfully managing post-discharge follow-up to minimize care gaps and reduce avoidable readmissions. - Timely retrieval and reconciliation of outside medical records to support care team decision-making. - High completion rates on outstanding provider orders through consistent, proactive patient follow-up. - Building and maintaining strong professional relationships with the Care Navigator team and GGH Nurse Practitioners. - Timely, accurate, and thorough documentation in all systems of record. - Meeting and exceeding call quality standards. Requirements: - Education - 1–2 years of post-high school education or an associate’s degree; bachelor’s degree in health sciences, social work, public health, or a related field is a plus. - Must have Medical Assistant Certificate & have worked as an MA for 2+ years - Experience - 1–3 years of experience working in standard operating systems (Windows, MS Word, MS Excel, Internet, and other applicable software). - 1–3 years of experience in a patient-facing healthcare role. - Skills - Excellent verbal and written communication skills, including the ability to communicate complex health information in an accessible and empathetic way. - Outstanding phone skills with sensitivity toward protected health information (PHI) and HIPAA compliance. - Familiarity with medical terminology and basic understanding of chronic disease management in older adults. - Must be organized, detail-oriented, and able to multitask in a fast-paced care coordination environment. - Must be adaptable, a team player, and comfortable working both independently and collaboratively. - Professionalism in appearance, communication, and demeanor. - Solid critical thinking and problem-solving skills with the ability to manage complex, multi-step patient situations. - Preferences - Healthcare experience in a patient-facing or care coordination role (Strongly Preferred). - Experience with or training in motivational interviewing, health coaching, or behavioral change techniques. - Experience retrieving medical records from hospitals, EHR systems, or external providers. - Familiarity with post-discharge care workflows, transitions of care, or case management principles. - Experience with value-based care models, population health management, or Medicare Advantage programs. - 1+ years of experience working with Medicare or senior/geriatric populations. - Experience with HEDIS gap closure or quality improvement initiatives. - 1+ years of call center experience and managing phone queues. - Basic Excel skills: navigation, data entry, filtering, and sorting. - Knowledge of or experience with EHR/EMR platforms. - Certification in care coordination, patient navigation, or a related area (e.g., CCM, ACM, CPHQ) is a plus