Care Transition Navigator

Overview

The Care Transition Navigator will be responsible for ensuring a safe transition from the acute care setting to home care by collaborating with all members of the health care team, such as case management, physicians, and external vendors, including patients and families. The Care Transition Navigator will complete a bedside assessment, identifying high risk medical and psychosocial needs, to ensure continuity of care with the goal of preventing avoidable rehospitalizations. The Care Transition Navigator will be responsible for meeting and/or exceeding admission goals as set by sales leadership.

 

Salary Potential: $80K inclusive of an opportunity for competitive compensation based on base salary with minimum commission expectation of 15 admits.

Responsibilities

Job Responsibilities

• Responsible for direct marketing and sales in assigned territory.
• Integrates evidence-based clinical guidelines in development of patient-centered transition plans
• Engages with patients, family, and caregivers as well as the inpatient care team during hospitalization to obtain appropriate information needed for smooth transition.
• Conducts onsite hospital assessment and medication reconciliation within 24 hours of referral to help reduce re- hospitalization and collaborate with care team to reduce hospitalization.
• Completes clinical comment intake notes to support admitting home health clinicians.
• Schedules patients follow up appointment with primary care physician within 3 days of post discharge.
• Conducts follow up phone call within 48 hours of facility discharge.
• Participates in care coordination with agency staff, contractors, patients, and referral partners.
• Completes workflow tasks and other assignments to the Care Transition Navigator in the Agency's electronic medical record.
• Receives and enters orders from all approved licensed practitioners and physicians involved in the plan of care and ensures the orders are approved by the responsible physician.
• Ensures effective communication with all physicians involved in a patient's plan of care and other health care practitioners (as appropriate).
• Educates patients/caregivers and coordinates with the Client Care Center (CCC) regarding participation in telephonic and virtual care.
• Follows up on pending referrals to ensure timely patient admission in collaboration with the Intake Coordinator.
• Prepares for and participates in case conference in collaboration with other healthcare team members.
• Participates in home health re-hospitalization mitigation strategies.
• Meets mandatory continuing education requirements of the Agency and licensing board.
• Uses effective interpersonal relations and communication skills; facilitates the use of these skills by other team members to achieve desirable outcomes.
• Participates in Agency-sponsored in-service training.

 

Physical, Mental, Miscellaneous Demands

• Prolonged sitting required, with the ability to operate office equipment which may include heavy lifting, bending, and standing.
• Requires the ability to always handle stressful situations in a calm and courteous manner.
• Prolonged standing and walking required, with the ability to lift up to 50 lbs.
• Requires working under some stressful conditions to meet deadlines and Agency needs.
• Must have and maintain valid Driver's License, and proof of current valid auto liability insurance.
• Requires current CPR certificate, and the ability to maintain a current CPR certificate. Other requirements the hospital and facility may require for entry as a vendor (ex: proof of Hepatitis B vaccine, flu vaccine.) Proof of Covid-19 vaccination required.
• Work deals mostly with areas such as preparing and reading data and figures, records, reports, visual inspection involving small details. Although important, depth perception and field of vision (peripheral) are not as critical as the ability to distinguish small details and markings very near to the observer.
• Requires ability to grasp, pull, push, carry or otherwise manipulate objects; ability to perform tasks requiring action of muscles or groups of muscles and foot and/or hand-eye coordination.
• Requires ability to communicate clearly and make self-understood effectively in face-to-face interactions; articulate with accuracy to communicate using phone.
• Requires ability to hear and receive verbal instructions correctly, answer phones, communicate professionally with people in situations with some background noise.
• Requires ability to concentrate on fine detail with frequent interruption; ability to focus attention on tasks for 10-20 minutes at a time on a continuous basis, 20-60 minutes on occasion.
• Requires ability to understand and relate to specific ideas one at a time and to the concepts behind specific ideas; ability to remember verbal and written tasks/assignments from a few hours to several day periods.

 

Transportation: Reliable transportation and valid and current auto liability insurance.

 

Environmental and Working Conditions: Performs duties in an office/facility environment during Agency operating hours promoting efficient functioning and coordination of all Agency activities to ensure the highest level of professional patient care. Ability to work a flexible schedule; ability to travel locally; some exposure to unpleasant weather. 80% of time spent in the assigned hospital accounts/facility settings. Other 20% of time spent in office setting or in the community.

Qualifications

Education: Graduate of an accredited Diploma, Associate or Baccalaureate School of Nursing or graduate of an accredited university/program with a Bachelor, Master, and/or Doctorate degree in Physical Therapy. May be required to complete HHS' Computer Based Training for appropriate category(ies) of license.

Licensure: Current license as a Registered Nurse (RN) or Licensed Vocational Nurse (LVN)/Licensed Practical Nurse (LPN) in state of residence and/or in accordance with the Nurse Licensure Compact (NLC) or active Physical Therapy (PT) Licensure of Physical Therapy Examiners in the state of employment, and a current Driver's License.

 

Experience: Minimum of two years of clinical experience as a RN, PT, LVN, or LPN. One year experience in home health care preferred.

Skills: Nursing or Physical Therapy skills as defined as generally accepted standards of practice. Excellent interpersonal skills and the ability to communicate effectively with referral partners, patients, and all segments of the staff. Demonstrates proven decision-making skills. Goal driven, relationship builder, motivation, and territory management.

 

 

 

We offer the following competitive benefits to support you, your family, and your furry family members too!

• Newly improved mileage reimbursement
• Newly improved benefits packages
• Pet Insurance Coverage
• Paid Time Off
• Paid Holidays...plus 2 bonus floating holidays!
• Family Medical Leave
• Tuition Reimbursement
• 401k Plan with a Company Match
• Legal Aid
• Identify Theft Plan
• Perks and Discounts

Employment Type: FULL_TIME