Care Transitions Navigator

Hendricks Regional Health; Danville (IN); On-site; USD 55,000 - 70,000; Full time

Job summary

Hendricks Regional Health in Danville, IN is seeking a Case Manager Extender to support patients transitioning from hospital care. You will assist with planning, access to services, and coordination across medical, psychosocial, and economic needs under RN or SW supervision.

This role emphasizes collaboration with physicians, outpatient providers, and community partners to reduce fragmentation, improve patient engagement, and promote seamless transitions of care.

Qualifications

• Knowledge of discharge planning and related regulations.
• Ability to promote patient and family engagement.
• Skilled in handling complex and sensitive information.

Responsibilities

• Assess and develop initial screen for non-complex admissions under RN/SW supervision.
• Facilitate access to services (SNF, home care, hospice, DME, transport) pre/post admission.
• Reassess plan and monitor changes for low-risk patients.
• Develop partnerships with physician practices and outpatient providers.
• Serve as point person for post-acute care providers and HRH physician practices.
• Ensure system integration and interdisciplinary coordination of care.
• Maintain contact information with community partners.
• Handle Medicare messages and Observation letters.
• Float as assigned by TOC clinical manager.
• Utilize case management for inpatients/outpatients as needed.
• Ensure accurate disposition coding and After Visit Summary.
• Participate in department, hospital and community transitions of care meetings.
• Manage TOC DME Loaner closet and department resources.
• Handle department communications including calls to main office.

Skills

Healthcare knowledge

Discharge planning regs

Patient engagement

Analytical thinking

Budget management

Computer literacy

Written communication

Diversity sensitivity

Confidentiality

Stress management

Ethics & compliance

Education

Bachelor's degree preferred

Healthcare experience

Job description

Hendricks Regional Health in Danville, IN is seeking a Case Manager Extender to support patients transitioning from hospital care. You will assist with planning, access to services, and coordination across medical, psychosocial, and economic needs under RN or SW supervision.

This role emphasizes collaboration with physicians, outpatient providers, and community partners to reduce fragmentation, improve patient engagement, and promote seamless transitions of care.