25 Transition Care Navigator

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.