Transitions of Care Navigator
Remote
CARE Delivery – Care Coordination /
Full Time /
Remote
About Synapticure
As a patient and caregiver-founded company, Synapticure provides instant access to expert neurologists, cutting-edge treatments and trials, and wraparound care coordination and behavioral health support in all 50 states through a virtual care platform. Partnering with providers and health plans, including CMS' new GUIDE dementia care model, Synapticure is dedicated to transforming the lives of millions of individuals and their families living with neurodegenerative diseases like Alzheimer’s, Parkinson’s, and ALS.
The Role
Synapticure is seeking a Transitions of Care Navigator (TOC Navigator) to support patients and caregivers during critical care transitions from hospitals or other healthcare settings back into the community. In this role, you will ensure that patients receive the education, resources, and follow-up care they need to prevent readmissions, improve outcomes, and enhance satisfaction.
You will serve as a liaison between patients, caregivers, and healthcare providers, developing personalized care plans, monitoring progress, and coordinating services to create a seamless transition experience. This position requires excellent communication skills, strong problem-solving abilities, and a passion for supporting vulnerable populations through continuity of care.
Job Duties – What you’ll be doing
- Collaborate with physicians, discharge planners, social workers, and primary care providers to ensure safe and effective care transitions
- Conduct patient assessments to identify medical, psychological, and social barriers to successful discharge
- Create and implement individualized care plans aligned with discharge instructions and patient needs
- Provide patients and families with clear education on medications, treatments, follow-up appointments, and lifestyle changes
- Educate patients on recognizing warning signs that may require urgent or emergency care
- Schedule follow-up appointments with PCPs, specialists, or community services and monitor adherence
- Conduct post-discharge follow-ups via phone, telehealth, or in-person visits to track patient progress and address unmet needs
- Act as a liaison between patients, caregivers, and providers to ensure clear communication and timely care delivery
- Document all interactions, progress, and follow-ups in electronic health record systems
- Report patient outcomes, including readmission rates and satisfaction data, to refine processes and improve care coordination
- Work closely with multidisciplinary teams to ensure continuity of care and participate in case reviews as needed
Requirements – What we look for in you
- Bachelor’s degree from an accredited institution preferred
- Minimum of 3 years of experience in transitions of care or related healthcare settings
- Proficiency in using virtual visit platforms, EHRs, and scheduling systems
- Strong verbal, written, and organizational skills, with the ability to work effectively in a diverse team
- Experience collecting and documenting clinical and demographic data accurately and in a timely manner
- Strong problem-solving skills, with the ability to make sound decisions and collaborate effectively when needed
- Adaptable and resourceful, with a growth mindset and the ability to thrive in a fast-paced, evolving environment
- Proven ability to establish cooperative working relationships with patients, colleagues, and community providers
Preferred Qualifications
- Experience with neurodegenerative disease patient populations
- Bilingual fluency in Spanish (written and verbal) to support diverse patients and caregivers
We’re founded by a patient and caregiver, and we’re a remote-first company. This means our values are at the heart of everything we do, and while we’re located all across the country, these principles are what tie us together around a common identity:
- Relentless focus on patients and caregivers. We are determined to provide an exceptional experience for every patient we serve, and we put their needs first in everything we do.
- Embody the spirit and humanity of those living with neurodegenerative disease. Inspired by our founders, families, and personal experiences, we meet every challenge with empathy, compassion, kindness, and hope.
- Seek to understand, and stay curious. We start by listening to patients, caregivers, and partners. We communicate authentically and with humility, knowing there is always something to learn.
- Embrace the opportunity. We act with urgency, accountability, and optimism to advance our mission.
Competitive salary commensurate with experience
Comprehensive medical, dental, and vision coverage
401(k) plan with employer matching
Remote-first work environment with home office stipend
Generous paid time off and sick leave
Professional development and career growth opportunities
