25 Transition Care Navigator

SGHS • Brunswick, GA

15h

About The Position

The Transition Care Navigator role involves reviewing daily hospital discharge reports to identify patients eligible for Transitional Care Management services. This includes contacting discharged patients within regulatory timeframes to complete post-discharge outreach. The navigator will assess the patient's condition, medication adherence, understanding of discharge instructions, and any new or worsening symptoms. They will also coordinate follow-up appointments, identify barriers to recovery, and connect patients with appropriate resources. Accurate documentation in the electronic medical record and compliance with CMS requirements are essential. Collaboration with various healthcare partners and participation in quality improvement initiatives are also key aspects of this role.

Requirements

• Experience in healthcare
• Familiarity with electronic medical records
• Knowledge of CMS Transitional Care Management documentation and billing requirements

Responsibilities

• Review daily hospital discharge reports and identify patients eligible for Transitional Care Management services.
• Contact discharged patients within required regulatory timeframes to complete post-discharge outreach.
• Assess the patient's overall condition following discharge, including medication access and adherence, understanding of discharge instructions, new or worsening symptoms and questions or concerns regarding their care plan.
• Coordinate and schedule timely follow-up appointments with the primary care provider or appropriate specialists.
• Identify barriers to recovery, such as transportation, financial concerns, medication affordability, or home support needs, and coordinate appropriate resources.
• Document all patient interactions accurately and completely within the electronic medical record.
• Maintain compliance with CMS Transitional Care Management documentation and billing requirements.
• Collaborate with physicians, advanced practice providers, nursing staff, hospitals, home health agencies, skilled nursing facilities, pharmacies, and other healthcare partners to coordinate patient care.
• Participate in quality improvement initiatives focused on reducing readmissions and improving patient satisfaction.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed