Care Transition Navigator – Post-Discharge Care Coach

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

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