Navigator, Transitions of Care-Northern New Jersey

Description Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community. Together, we keep getting better – advancing our mission to transform healthcare and serve as a leader of positive change. The Transitions of Care Navigator is a member of the healthcare team and is responsible for coordinating, communicating and facilitating the care of patients with Medical, Behavioral and Maternal Health needs. The navigator is accountable for a designated caseload determined by the careful daily selection of eligible patients. They assess, plan and facilitate, with patients/families and healthcare professionals involved in the patient's care, to meet treatment goals and arrange for the appropriate next steps. Oversees inter‑facility coordination and handoff between acute and outpatient services. This position will be based in the Northern Region (Hackensack University Medical Center and Palisades Medical Center). Responsibilities All patients admitted for medical care will be screened for potential eligibility to the Transitions of Care (TOC) program and enrolled. Meet directly with patient/family to assess needs and develop an individualized needs assessment in collaboration with the Transitions Assistant. Facilitate communication and coordination between members of the healthcare team and involve the patient/family in decision‑making to minimize fragmentation of services, manage resources and remove barriers to the discharge plan of care. Develop a TOC plan, in collaboration with the patient/family, patient caregiver, patient support persons and healthcare team to provide maximum benefit for each patient; confirm the patient has a primary care provider, OB‑Gyn or behavioral health provider upon discharge and refer appropriately to an FQHC or provider that accepts the patient's medical insurance. Participate in Multidisciplinary Team Rounds specific to the assigned unit; bring forth issues that impact the patient’s discharge and risk of readmission for discussion and resolution with the healthcare team and Transitions Assistant. Work collaboratively with all members of the multidisciplinary healthcare team and community partners for timely and appropriate transitions to the next appropriate level of care. Maintain current and up‑to‑date information on community resources and refer patients to those resources that will enhance their life and clinical outcomes; consult with other community agencies and committees to identify potential resources to support patients and their families; actively work to find community partners. Document and communicate information to the Multidisciplinary Team to coordinate and maximize care; the Electronic Health Record must reflect the needs of the patient, any education needed based on the patient's medical history, coordination of follow‑up care, and referral to complex behavioral care services. Provide patients and families with community resources and discharge care coordination options. Participate actively on appropriate workgroups, and/or meetings; serve as a positive problem solver; identify and refer quality issues for review to the Regional Manager. Reassess periodically and evaluate against care goals and the plan of care; when indicated, revise the plan or goals. Medical records must reflect that each patient’s discharge plan is reassessed in response to changes in patient needs and social determinants of health. Collaborate with social work and outside agencies to support crisis intervention, counseling support and referrals, abuse/neglect, psychosocial assessment and referrals to ICMS or PACT Programs as needed. Complete all other necessary duties with attention to detail and in a timely manner. Collaborate with Utilization Review Nurses. Referrals include: Primary Care Physicians Behavioral Health Providers HUMG Internal Medicine Clinic Human Dimensions Program Meds to Bed program Lyft Concierge Transportation Financial Assistance Office HMH Quit Center North Hudson Clinics Medication Assistance Programs NowPow Qualifications Education, Knowledge, Skills and Abilities Required Bachelor’s degree. Knowledge of managed care principles. Knowledge of the New Jersey Quality Improvement Program and its quality metrics. Knowledge of the healthcare delivery system, utilization and review, and case review procedures. Knowledge of social determinants of health. Good working knowledge of benefit plans such as Medicaid, HMOs, etc. Computer skills including Google Docs and data entry. Delegates effectively to the Transitions Assistant. Strong organizational and problem‑solving skills. Excellent oral and written communication and interpersonal skills. Exceptional communication skills to enable collaboration with physicians, patients, families, and ancillary staff. Excellent critical‑thinking skills. Ability to work in a fast‑paced team environment. Ability to prioritize and multitask. Ability to make sound, independent clinical judgments and act professionally under pressure. Demonstrate ability to provide age‑appropriate patient education and written and verbal communication skills, cultural competency, customer service skills, and health literacy. Education, Knowledge, Skills and Abilities Preferred Three to five years of clinical experience. Experience with relevant systems such as Google Docs and EPIC. Master’s degree. Licenses and Certifications Preferred Certified Case Manager or Accredited Case Manager Certification. Compensation & Benefits HMH is committed to pay equity and transparency for our team members. The posted rate of pay in this job posting is a reasonable good faith estimate of the minimum base pay for this role at the time of posting in accordance with the New Jersey Pay Transparency Act and does not reflect the full value of our market‑competitive total rewards package. The starting rate of pay is provided for informational purposes only and is not a guarantee of a specific offer. Posted hourly rates may be stated as an annual salary in the offer and posted annual salaries may be stated as an hourly rate in the offer, depending on the level and nature of the job duties and credentials of the candidate. The base compensation determined at the time of the offer may be different than the posted rate of pay based on a number of non‑discriminatory factors, including but not limited to: Labor Market Data: Compensation is benchmarked against market data to ensure competitiveness. Experience: Years of relevant work experience. Education and Certifications: Level of education attained, including specialized certifications, credentials, completed apprenticeship programs or advanced training. Skills: Demonstrated proficiency in relevant skills and competencies. Geographic Location: Cost of living and market rates for the specific location. Internal Equity: Compensation is determined in a manner consistent with compensation ranges for similar roles within the organization. Budget and Grant Funding: Departmental budgets and any grant funding associated with the job position may impact the pay that can be offered. Some jobs may also be eligible for performance‑based incentives, bonuses, or commissions not reflected in the starting rate. Certain positions may also be eligible for shift differentials for work performed on evening, night, or weekend shifts. In addition to our compensation for full‑time and part‑time (20+ hours per week) job positions, HMH offers a comprehensive benefits package, including health, dental, vision, paid leave, tuition reimbursement, and retirement benefits. Minimum rate of $82,513.60 annually. #J-18808-Ljbffr Hackensack Meridian Health