Care Navigator (Patient Engagement Specialist)
Care Navigator (Patient Engagement Specialist) About Linea Linea is reimagining cardiorenal metabolic disorder management through the intelligent fusion of technology and clinical expertise. We're building AI-enhanced care coordination systems that allow clinical teams to reach more patients with greater impact during the critical 90-day post-hospitalization period. We deliver proactive, data-driven patient engagement for patients with heart failure, fluid management needs, and other metabolic diseases that reduces readmissions and improves outcomes. The Role As a Care Navigator at Linea, you are first and foremost a patient advocate and care coordinator who helps patients navigate the critical 90-day post-hospitalization period. You'll spend 75% of your time directly engaging patients through proactive calls, care coordination, and interventions to prevent rehospitalization. Your day-to-day involves calling newly discharged patients to introduce them to the program, reviewing their discharge plans, assessing medical symptoms, coordinating appointments with specialists, and systematically addressing social determinants of health barriers like transportation, food access, and medication affordability. What makes this role different: You'll leverage technology-enhanced workflows and automated systems (AI-generated patient summaries, alert systems, text messaging campaigns) to reach far more patients than traditional care navigation models allow. The remaining 25% of your time is spent helping us optimize these systems—identifying what's working, what's not, and how we can scale personalized care to hundreds of patients. We're looking for care navigation leaders who are frustrated by the constraints of traditional models and ready to pioneer a new paradigm. You believe high-quality, personalized care coordination shouldn't be limited to traditional caseloads, and you're excited to help us prove that technology can amplify—not replace—the human connection that drives health outcomes.
Key Responsibilities
Patient Engagement & Care Coordination (75%)
- Conduct proactive outreach calls to newly discharged patients to introduce the program and establish rapport
- Review hospital discharge plans to ensure patients understand medications, appointments, and care instructions
- Perform regular symptom monitoring calls to identify early signs of decompensation (shortness of breath, weight gain, edema, medication side effects)
- Systematically assess social determinants of health and connect patients with resources (transportation, food access, medication assistance, housing support)
- Schedule and coordinate appointments with PCPs, cardiologists, and nephrologists while reducing no-show rates
- Obtain and organize medical records from multiple healthcare systems
- Monitor patient-reported data and escalate clinical concerns to nurse practitioners following established protocols
- Re-engage patients showing declining participation using motivational interviewing techniques
- Triage patient needs across three phases: newly identified (Triage), awaiting enrollment (Pre-enrolled), and actively engaged (Enrolled)
Contributing to Innovation & Continuous Improvement (25%)
- Identify workflow inefficiencies and share ideas for how technology could help reach more patients
- Provide feedback on automated text messaging effectiveness based on patient responses
- Track what interventions work best and share successful approaches with the team
- Help test new platform features and report on usability from the care navigator perspective
- Share patterns you notice in patient barriers that could inform systematic solutions
- Document insights from patient conversations that help refine our care protocols
- Participate in weekly team meetings to collaborate on improving care delivery
Qualifications
Education & Experience:
- Master's degree preferred
in health sciences, public health, social work, nursing, psychology, or related field (bachelor's accepted with exceptional experience)
- Minimum 2 years
in care coordination, case management, patient navigation, or health coaching
- Openness to innovation
—you're excited about leveraging technology to reach more patients and willing to help pioneer a new model of care navigation
- Experience with
cardiorenal metabolic disorders , heart failure, fluid management, and metabolic diseases strongly preferred
- Success working with
medically complex and