Navigator, Transitions of Care-Central New Jersey

About the role

The Transitions of Care Navigator plays a crucial role in coordinating and facilitating the care of patients with Medical, Behavioral, and Maternal Health needs. This role is essential in ensuring smooth transitions from acute care to outpatient services and beyond.

Responsibilities

• All patients admitted for medical care will be screened for potential eligibility to the Transitions of Care (TOC) program and enrolled if eligible.
• Makes direct contact with patients/families to assess their needs and develop an individualized needs assessment, collaborating with the Transitions Assistant to plan care.
• Facilitates communication and coordination among healthcare team members and involves the patient/family in the decision-making process to minimize fragmentation of services and manage resources.
• Develops a TOC plan in collaboration with the patient/family, patient caregiver, and healthcare team to provide maximum benefit for each patient, aligning with patient quality metrics.
• Confirms the patient has a primary care provider, OB-GYN, or Behavioral Health provider upon discharge and refers appropriately to an FQHC or provider accepting the patient's medical insurance.
• Participates in Multidisciplinary Team Rounds to discuss and resolve issues impacting patient discharge and the risk of readmission with the patient's health care team and Transitions Assistant.
• Works collaboratively with all members of the multidisciplinary health care team and community partners for timely and appropriate transitions to the next level of care.
• Maintains current and up-to-date information on community resources and refers patients to those resources that will enhance their life and clinical outcomes.
• Collaborates with social work and outside agencies to support crisis intervention, counseling, referrals, abuse/neglect, psychosocial assessments, and referrals to ICMS or PACT Programs as needed.
• Documents and communicates information to the Multidisciplinary Team to coordinate and maximize care.

Qualifications

• Bachelor's degree.
• Knowledge of managed care principles.
• Knowledge of Quality Improvement Program - New Jersey program and its Quality Metrics.
• Knowledge of health care delivery system, utilization, and review procedures.
• Good working knowledge of benefit plans, including Medicaid-HMOs.
• Computer skills, including Google Docs and data entry.
• Delegates effectively to the Transitions Assistant.
• Strong organizational and problem-solving skills.
• Excellent oral and written communication and interpersonal skills.
• Exceptional communication skills to enable communication and collaboration with physicians, patients, families, and ancillary staff.
• Excellent critical thinking skills.
• Ability to work in a fast-paced team environment.
• Ability to prioritize and multitask.
• Ability to make sound, independent clinical judgments and act professionally under pressure.
• Demonstrated ability to provide age-appropriate patient education, written and verbal communication skills, cultural competency, and customer service skills, as well as health literacy.

Preferred Qualifications

• Three to five years' clinical experience.
• Experience with relevant systems, such as Google Docs and EPIC.
• Master's degree.
• PREFERRED: Certified Case Manager or Accredited Case Manager Certification.