Population Health Transition Navigator

Duties:

• Navigates Epic reports and databases to identify patients for program enrollment

• Identifies patient/family education needs and ensures that patient/family members have adequate information to participate in transition planning.

• Critically evaluates and analyzes physical and psychosocial assessment data.

• Interprets screening and selective laboratory/diagnostic tests.

• Initiates and maintains communication and collaboration with physicians, social workers, care team leaders, staff nurses, other care giving disciplines, and patients/families to develop, implement, and evaluate a transition plan of care for each patient.

• Conducts a comprehensive patient/family assessment and transition/home care planning evaluation upon program enrollment to initiate and maintain the patient's transitional plan of care.

• Monitors the achievement of clinical outcomes and communicates with inpatient teams, primary and specialty physicians and staff, regional providers, and community resources (Home Health) regarding unanticipated variances.

• Assesses complexity of care needs and potential/actual issues or gaps in care.

• Arranges post-discharge medical and community referrals for patients with health problems requiring further evaluation and/or additional services.

• Advocates for patients and families within the healthcare system with community providers and across the continuum of care.

• Identifies, tracks, and conducts root cause analyses on readmissions to address programmatic and system-wide improvements.

• Works with physicians, providers, researchers, and post-acute care leadership to identify broader system issues affecting patient care.

• Coordinates and facilitates patient progression throughout the continuum. Collaborates with all members of the healthcare team and external customers.

• Participates in clinical performance improvement activities to achieve set goals.

• Applies advanced critical thinking and conflict resolution skills using creative approaches.

• Supports post-acute care leadership with system-level quality improvement.

Qualifications:

• Bachelor's Degree and/or graduate of an accredited program related to licensure required

• Master's degree in a health care-related field preferred

• OT, PT, PT Assistant (MA licensed) preferred

• ACMA certification as a case manager preferred

• Minimum 5 years' experience, including at least 2 years post-acute, care coordination and/or case management experience.

Skills and Abilities:

• Ability to establish strong rapport and relationships with patients and staff.

• Proficient in Microsoft Office and industry related software programs.

• Computer skills in word processing, database management and spreadsheets.

• Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.

• Ability to maintain client and staff confidentiality.