Care Transition Navigator PRN

Methodist Health System • Celina, TX

6d • Onsite

About The Position

Job Purpose: The Care Transitions Navigator will coordinate activities that promote quality outcomes, patient throughput and discharge planning while supporting a balance of optimal care and appropriate resource utilization. The Care Transitions Navigator will identify potential barriers to patient throughput and quality outcomes minimizing delays in discharge plans. Age Specific Care Considerations: Adults: 18+ years – 35 years Adults: 35+ years – 65 years Adults: 65+ years Children A: 18+ months – 3 years Children B: 3+ years – 5 years Children C: 5+ years – 12 years Children D: 12+ years – 18 years Infants: 0 – 18 months Education: Bachelor’s degree in Social Work, Master’s degree in Social Work, Registered Nurse with BSN preferred. Hospital case management experience preferred. Licenses and/or Certifications (Required and Preferred): LMSW/LBSW, or RN as licensed by the Texas Board of Examiners, CCM or ACM preferred Related Work Experience and Other Skills: 1 Year related work experience and ability to prioritize multiple tasks in a fast paced environment, ability to periodically flex work schedule as indicated by client or hospital needs, ability to develop and maintain good working relationship with all levels of staff, ability to communicate in an articulate manner, both verbally and in writing, and demonstrate empathy, flexibility and objectiveness, and maintains a professional approach to handling confidential information. Physical Demands and Work Environment: Physical Factors (% of Time): •20 - Standing Stationary •60 - Standing/Moving About •15 – Sitting •2 – Climbing •20 - Bending (stooping/crouching) •2 – Kneeling •1 – Crawling •30 – Reaching •90 – Handling •90 – Talking •0 - Driving •15 – Smelling Hearing (% of Time): •100 - Normal Noise Level •0 - Occasional Loud Noise •0 - Constant/Very Loud Noise •0 - Constant Low Level Noise Hazardous Conditions (% of Time): •5 - Respiratory Irritants •50 - Skin Irritants •50 - Allergic Irritants •50 - Wet Work – Hands •1 - Wet Work – Feed •0 - Operation of Heavy Equipment •0 - Climbing of Ladders •0 - Working in High Places •50-75 - Use of Electrical Equipment •25-50 - Use of Sharp Utensils •80 - Exposure to Blood and Body Fluids Carrying (% of Time): •50 - Up to 10 Lbs •30 - 10-20 Lbs •10-30 - 20-50 Lbs •10 - 50-100 Lbs •0 - 100+ Lbs Lifting (% of Time): •45 - Up to 10 Lbs •30 - 10-20 Lbs •10-30 - 20-50 Lbs •10 - 50-100 Lbs •0 - 100+ Lbs Push/Pull (% of Time): •10 - Up to 10 Lbs. •10 - 10-20 Lbs •30 - 20-50 Lbs •10 - 50-100 Lbs •10 - 100+ Lbs Visual Demands (Yes or No): •Yes/No - Vision Essential •Yes/No - Vision Not Essential Environmental Demands (% of Time): •100 – Indoor •0 – Outdoor •0 - Hot Environment •0 - Cold Environment Other (% of Time): •10 - Visual Strain Job Roles Duty 1: Assessment and discharge planning A comprehensive psychosocial and medical needs assessment should be completed on each assigned patient in order to facilitate an appropriate and workable discharge plan. Based on identified needs and payer restrictions, referrals will be made to appropriate post-acute providers. Care will be taken to ensure interdisciplinary input along with patient and family preferences. Duty 2: Documentation Documentation in the medical record will be completed to communicate care coordination activities and patient/family interactions to the health care team. The documentation will be in all software programs that are utilized by care management staff and will include the care management plan, potentially avoidable days, payer and referral information, and any other material that needs to be known to individuals involved in the management of the patient. Duty 3: Resource coordination Facilitation of patient throughput and smooth transitions of care throughout the hospital stay is a primary goal of effective care navigation, and current knowledge of federal, state and community regulations and resources is an absolute necessity. The Care Transitions Navigator is the liaison between providers, payers, physicians, patients and families to ensure that costs are controlled, patient needs are met, patient safety is maintained and information is shared in a timely manner. Patients without traditional resources will be identified and referred to education programs and community assistance programs and resources for which they qualify. Duty 4: Team Work The Care Transitions Navigator must consistently be an active participant in the health care team – taking a leadership role when necessary and a follower role when that is the most beneficial to the welfare of the patient. He/she must develop strong working relationships with physicians and other hospital staff while maintaining working relationships with the post-acute providers who will continue the care after the patient is discharged. The Care Transitions Navigator will be the teacher or coach when necessary and the student when that is the most helpful role. He/she must work effectively with the Centralized UR Team to ensure the best financial outcome for the patient and hospital. Duty 5: Professional development The Care Transitions Navigator will participate in educational activities, care conferences, inservice opportunities and staff meetings. All licensing and certification education requirements must be maintained. Duty 6: Participates in MHD’s Value Management Program and Related Programs Current knowledge of federal, state, hospital and JCAHO guidelines relating to medical, utilization management and quality improvement must be maintained and followed. The Care Transitions Navigator must be prepared to issue Code 44 letters, Hospital Initiated Notices of Noncoverage and any other required federal communication according to published guidelines. The navigator has a unique opportunity to coach and teach physicians and other healthcare team members about government regulations and is expected to participate in clinical improvement processes when invited to do so.. The Care Transitions Navigator must complete a length of stay and readmission,- risk assessment on each assigned patient. Duty 7: Other duties as assigned. Methodist Celina Medical Center is located on a 40+ acre campus just off of Dallas Parkway, and will serve as the community’s first full-service hospital, serving Celina and surrounding communities. The four-story medical center will open with 51 beds, with plans for expansion, and will feature a range of services including cardiology, women’s services, orthopedics, robotic surgery, and more. The campus will also include a 40,000-square-foot medical office building. The $237 million facility will be one of Celina’s largest employers in the fastest growing city in the country. We strive to have a diverse workforce that reflects the communities we serve. Methodist Health System is a faith-based organization with a mission to improve and save lives through compassionate, quality healthcare. For nearly a century, Dallas-based Methodist Health System has been a trusted choice for health and wellness. Named one of the fastest-growing health systems in America by Modern Healthcare, Methodist has a network of 12 hospitals (through ownership and affiliation) with nationally recognized medical services, such as a Level I Trauma Center, multi-organ transplantation, Level III Neonatal Intensive Care, neurosurgery, robotic surgical programs, oncology, gastroenterology, and orthopedics, among others. Methodist has more than two dozen clinics located throughout the region, renowned teaching programs, innovative research, and a strong commitment to the community. Our reputation as an award-winning employer shows in the distinctions we’ve earned: Great Place to Work Certified 2026-2027 Glassdoor’s Best Places to Work 2025 & 2026 Glassdoor’s Best Places to Work in Healthcare, Biotech & Pharma 2026 TIME’s Best Companies for Future Leaders 2025 & 2026 Newsweek’s America’s Most Admired Workplaces 2026 Glassdoor’s Best-Led Companies 2025 Fortune Best Workplaces in Health Care 2025 Military Friendly Gold Employer 2025 Becker’s Hospital Review 150 Top Places to Work in Healthcare 2025 Newsweek’s Americas Greatest Workplaces 2025

Requirements

• Bachelor’s degree in Social Work, Master’s degree in Social Work, Registered Nurse with BSN preferred.
• 1 Year related work experience and ability to prioritize multiple tasks in a fast paced environment, ability to periodically flex work schedule as indicated by client or hospital needs, ability to develop and maintain good working relationship with all levels of staff, ability to communicate in an articulate manner, both verbally and in writing, and demonstrate empathy, flexibility and objectiveness, and maintains a professional approach to handling confidential information.

Nice To Haves

• Hospital case management experience preferred.
• LMSW/LBSW, or RN as licensed by the Texas Board of Examiners, CCM or ACM preferred

Responsibilities

• Assessment and discharge planning A comprehensive psychosocial and medical needs assessment should be completed on each assigned patient in order to facilitate an appropriate and workable discharge plan. Based on identified needs and payer restrictions, referrals will be made to appropriate post-acute providers. Care will be taken to ensure interdisciplinary input along with patient and family preferences.
• Documentation Documentation in the medical record will be completed to communicate care coordination activities and patient/family interactions to the health care team. The documentation will be in all software programs that are utilized by care management staff and will include the care management plan, potentially avoidable days, payer and referral information, and any other material that needs to be known to individuals involved in the management of the patient.
• Resource coordination Facilitation of patient throughput and smooth transitions of care throughout the hospital stay is a primary goal of effective care navigation, and current knowledge of federal, state and community regulations and resources is an absolute necessity. The Care Transitions Navigator is the liaison between providers, payers, physicians, patients and families to ensure that costs are controlled, patient needs are met, patient safety is maintained and information is shared in a timely manner. Patients without traditional resources will be identified and referred to education programs and community assistance programs and resources for which they qualify.
• Team Work The Care Transitions Navigator must consistently be an active participant in the health care team – taking a leadership role when necessary and a follower role when that is the most beneficial to the welfare of the patient. He/she must develop strong working relationships with physicians and other hospital staff while maintaining working relationships with the post-acute providers who will continue the care after the patient is discharged. The Care Transitions Navigator will be the teacher or coach when necessary and the student when that is the most helpful role. He/she must work effectively with the Centralized UR Team to ensure the best financial outcome for the patient and hospital.
• Professional development The Care Transitions Navigator will participate in educational activities, care conferences, inservice opportunities and staff meetings. All licensing and certification education requirements must be maintained.
• Participates in MHD’s Value Management Program and Related Programs Current knowledge of federal, state, hospital and JCAHO guidelines relating to medical, utilization management and quality improvement must be maintained and followed. The Care Transitions Navigator must be prepared to issue Code 44 letters, Hospital Initiated Notices of Noncoverage and any other required federal communication according to published guidelines. The navigator has a unique opportunity to coach and teach physicians and other healthcare team members about government regulations and is expected to participate in clinical improvement processes when invited to do so.. The Care Transitions Navigator must complete a length of stay and readmission,- risk assessment on each assigned patient.
• Other duties as assigned.

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level
• Number of Employees: 1,001-5,000 employees