25 Transition Care Navigator

Southeast Georgia Health Systems, Inc.; Brunswick (GA); On-site; USD 55,000 - 75,000; Full time

Job summary

Southeast Georgia Health Systems, Inc. in Brunswick, GA is seeking a 25 Transition Care Navigator to support patients after hospital discharge.

You will review discharge data, identify candidates for Transitional Care Management and contact them within required timeframes. You will assess post-discharge needs, coordinate timely follow-up with the primary care provider or specialists, address barriers to recovery, document all interactions in the EMR, ensure CMS Transitional Care Management

Responsibilities

• Review discharge data to identify candidates for Transitional Care Management and contact them within required timeframes.
• Assess post-discharge needs, coordinate timely follow-up with primary care providers or specialists, and address barriers to recovery.
• Document all patient interactions in the EMR, maintain CMS Transitional Care Management compliance, and participate in quality-improvement initiatives to reduce readmissions.

Job description

Title: 25 Transition Care Navigator

Job Category: Health Care

Requisition Number: 25TRA004791

Job Type: Full-Time

Brunswick, GA, 31520, United States

Description

• Review daily hospital discharge reports and identify patients eligible for Transitional Care Management services and 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.

Equal Opportunity Employer
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