Care Transition Navigator
New Day Healthcare
- Beaumont, TX
- $67,000-72,000 per year
- Permanent
- Full-time
Reports to: VP of Patient Navigation
Salary Range: $67K-$72K + mileageJob Summary
The Care Transition Navigator is responsible for providing compassionate, patient-centered care through goals of care conversations, identifying healthcare needs, recommending resources, education on disease progression and treatment/care options, and coordination with internal and external partners. This role is a key contributor in ensuring continuity of care, education, advocacy and support for patients and families navigating chronic of life-limiting illness. The clinician collaborates across departments and with referral sources to optimize patient outcomes and access to New Day's full continuum of care.This is a Remote position with driving Covering Beaumont to Houston, TX area.QUALIFICATIONS
- Required: LPN, RN, or MSW
- Experience in hospice, palliative care, or home health preferred
- Strong knowledge of disease processes
- Excellent communication and interpersonal skills, with the ability to lead emotionally sensitive conversations
- Ability to work both independently and collaboratively in a fast-paced environment.
CLINICAL CARE & PATIENT SUPPORT
- Conducts psychosocial assessments to evaluate emotional, social, and environmental needs.
- Facilitates Goals of Care discussions, including treatment options, prognosis, &advance care planning.
- Supports patients and families in end-of-life and resource planning, including DNR, POA, and Advance Directives.
- Educates patients and families on disease progression, symptom expectations, and appropriate care strategies.
- Navigate patients and families through various care planning tasks such as coordination with specialists and available community resources.
- Develops and coordinates of individualized Goals of Care.
- Continuously evaluates the effectiveness of CDM services and adjusts Goals pf Care and triaging needs appropriately.
- Maintains communication with all parties involved in the patient’s care, including nursing, physicians, families, and external agencies.
- Makes timely and appropriate referrals to New Day Healthcare service lines such as hospice, home health, in-home services, CDS, pharmacy, and PDC.
- Collaborates with internal departments to ensure proper coordination and eligibility for CDM services.
- Participates in care connection meetings and case conferences to support ongoing collaboration.
- Builds and maintains relationships with external referral sources, including ALFs, SNFs, and other healthcare facilities.
- Provides education to referral partners and participates in marketing, outreach, and networking events as needed.
- Assists with community needs assessments to identify healthcare gaps and opportunities for service growth.
- Maintains accurate, timely, and relevant documentation in the EMR in accordance with agency standards.
- Manages scheduling, timesheets, and required reports promptly and efficiently.
- Participates in training and orientation of new staff as assigned.
- Engages in ongoing education and learning opportunities.
- Demonstrates commitment to cultural and emotional competence in all patient and team interactions.
- Upholds New Day Healthcare's mission and values in all patient and community interactions.