Transition Care Manager (RN)

Navvis • Newark, NJ

1d • Hybrid

About The Position

About Us: Navvis is a leading population health company, driving performance in value-based care. As an operating partner to some of the country’s most innovative health systems, physician enterprises, and health plans, we provide solutions that accelerate the journey to value-based care. Our approach is market-based – we respect the unique needs of populations in each community, including access to care, culture, values, and capabilities. Together with our partners, we set a new national standard in healthcare performance that delivers the affordability, quality, access, and experience that all patients deserve. Learn more at: www.navvishealthcare.com Role Overview: The Episode Coordinator serves as a critical component for the TEAM model. This coordinator will support patients leading up to and including the duration of the clinical episode. This individual will be the care management expert that completes regularly scheduled assessments, proactively engages the patients, and aligns community resources to ensure the best outcomes for the patient. The Coordinator reports directly to the Director of Clinical Transformation ensuring strong alignment, but will work across care continuum lines always with the patient experience at the center. As a Transition Care Manager: Manage patients attributed to CMS TEAM Episode to support optimized outcomes Attend hospital discharge planning meetings as needed to ensure post-discharge needs are addressed and patients are discharged to appropriate next sites of care Engage with patients including confirming contact information and document information about patient situation (home, stairs, lives alone, transportation, PCP, and specialist), and anticipated health related needs Complete regular outreaches to monitor patient progression through surgical recovery, identify readmission risks and work to resolve Serve as day-to-day partner to care management leaders across hospital and physician office sites in compliance with HMH Population Health and HMH ACO/CIN policies Participate in Physician Performance report outs with facility Physician Advisor and at quarterly hospital meetings Support the Director of Clinical Transformation and ongoing process improvement by developing and delivering case presentations and education to hospital teams Ensure escalation of cases to Physician Advisors in cases of disposition disconnect between Episode Coordinator recommendation and Discharge Planners’, Physical Therapist, or Hospitalists plans Episode Coordinator will cover these locations: o Hackensack University Medical Center o Palisades Medical Center (Safety Net) o JFK University Medical Center o Raritan Bay Medical Center o Jersey Shore University Medical Center o Bayshore Medical Center o Riverview Medical Center o Ocean University Medical Center o Southern Ocean Medical Center What Success Looks Like in this Role: Patients experience seamless transitions across the care continuum, with their needs proactively identified and addressed before, during, and after clinical episodes. Regular patient assessments and outreach are completed on schedule, with risks for readmission or complications identified early and mitigated. Discharge planning is consistently coordinated, ensuring patients are discharged to the most appropriate next site of care, with all post-discharge needs addressed.

Requirements

• RN required
• Bachelors in Nursing prepared required
• 3+ years experience in episode care management.
• Experience with value-based care management models such as BPCI, CJR, ACO

Responsibilities

• Manage patients attributed to CMS TEAM Episode to support optimized outcomes
• Attend hospital discharge planning meetings as needed to ensure post-discharge needs are addressed and patients are discharged to appropriate next sites of care
• Engage with patients including confirming contact information and document information about patient situation (home, stairs, lives alone, transportation, PCP, and specialist), and anticipated health related needs
• Complete regular outreaches to monitor patient progression through surgical recovery, identify readmission risks and work to resolve
• Serve as day-to-day partner to care management leaders across hospital and physician office sites in compliance with HMH Population Health and HMH ACO/CIN policies
• Participate in Physician Performance report outs with facility Physician Advisor and at quarterly hospital meetings
• Support the Director of Clinical Transformation and ongoing process improvement by developing and delivering case presentations and education to hospital teams
• Ensure escalation of cases to Physician Advisors in cases of disposition disconnect between Episode Coordinator recommendation and Discharge Planners’, Physical Therapist, or Hospitalists plans

Benefits

• Navvis offers a competitive benefits package including, but not limited to, medical, dental, vision, 401K with a safe harbor contribution and Paid Time Off plan starting at 2+ weeks.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level