Transitional Care Navigator Inpatient - FT Days

If you are interested, apply online and send resume to yadeleon@mlkch.org.

POSITION SUMMARY

The Transitional Care Navigator will serves as an integral part of a post-acute navigation team to ensure quality patient outcomes, patient satisfaction and continuity of care post discharge from the hospital. The role focuses on facilitating access to health care services, such as coordinating transportation, health insurance navigation, translation services, and other similar duties.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• This position reports to the Manager of Care Management and receives regular supervision and direction from the Care Management Transitional Care Nurse.
• Works with the inpatient Medicare and Medicaid population to coordinate transition out of the acute care setting in order to obtain appropriate follow up provider services and benefits as directed by the care coordination team and the contracted payer source. This includes arranging PCP or specialist appointments, referring to community clinics, faxing clinical information to post-acute providers, arranging authorization and transportation, following up on post-acute services arranged prior to discharge to ensure that patient has safe home situation, obtaining test results and other patient related duties as designated.
• Prioritizes and promotes MLKCMG Post-discharge clinic whenever possible to ensure effective communication, safety and quality in immediate post-discharge care.
• Attempts to have face-to face interactions for coordination with as many patients as possible prior to discharge.
• Documents all interventions in the patient medical record both timely and accurately including all elements of the post discharge plan. Performs transfer of accurate, pertinent patient information between all appropriate entities of the post-acute care continuum.
• Submits appropriate claims related to eligible Community Health Worker services under CalAIM to contracted payers through established internal processes.
• Works collaboratively with team members; promotes collaborative relationships with vendors, community and referral resources.
• May perform tasks such as securing community resources / information or other tasks. Participates in a team for data collection, health outcomes reporting, clinical audits and programmatic evaluation related to the Patient-Centered Medical Home and Medical Neighborhood initiatives.
• Other responsibilities and duties as assigned.

POSITION REQUIREMENTS

A.  Education

B.  Qualifications / Experience

C.   Special Skills / Knowledge

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