Care Transition Navigator

Title: Care Transition Navigator
Reports to: VP of Patient Navigation 
Salary Range: $67K-$72K + mileage 

Job Summary
The Care Transition Navigator is responsible for providing compassionate, patient-centered care through goals of care conversations, identifying healthcare needs, recommending resources, education on disease progression and treatment/care options, and coordination with internal and external partners. This role is a key contributor in ensuring continuity of care, education, advocacy and support for patients and families navigating chronic of life-limiting illness. The clinician collaborates across departments and with referral sources to optimize patient outcomes and access to New Day's full continuum of care.

This is a Remote position with driving Covering Beaumont to Houston, TX area.

QUALIFICATIONS

• Required: LPN, RN, or MSW
• Experience in hospice, palliative care, or home health preferred
• Strong knowledge of disease processes
• Excellent communication and interpersonal skills, with the ability to lead emotionally sensitive conversations
• Ability to work both independently and collaboratively in a fast-paced environment.

Key Responsibilities
CLINICAL CARE & PATIENT SUPPORT

• Conducts psychosocial assessments to evaluate emotional, social, and environmental needs.
• Facilitates Goals of Care discussions, including treatment options, prognosis, &advance care planning.
• Supports patients and families in end-of-life and resource planning, including DNR, POA, and Advance Directives.
• Educates patients and families on disease progression, symptom expectations, and appropriate care strategies.
• Navigate patients and families through various care planning tasks such as coordination with specialists and available community resources.

CARE COORDINATION & COLLABORATION

• Develops and coordinates of individualized Goals of Care.
• Continuously evaluates the effectiveness of CDM services and adjusts Goals pf Care and triaging needs appropriately.
• Maintains communication with all parties involved in the patient’s care, including nursing, physicians, families, and external agencies.
• Makes timely and appropriate referrals to New Day Healthcare service lines such as hospice, home health, in-home services, CDS, pharmacy, and PDC.
• Collaborates with internal departments to ensure proper coordination and eligibility for CDM services.
• Participates in care connection meetings and case conferences to support ongoing collaboration.

COMMUNITY ENGAGEMENT & PROGRAM DEVELOPMENT

• Builds and maintains relationships with external referral sources, including ALFs, SNFs, and other healthcare facilities.
• Provides education to referral partners and participates in marketing, outreach, and networking events as needed.
• Assists with community needs assessments to identify healthcare gaps and opportunities for service growth.

ADMINISTRATIVE DUTIES & PROFESSIONAL EXPECTATIONS

• Maintains accurate, timely, and relevant documentation in the EMR in accordance with agency standards.
• Manages scheduling, timesheets, and required reports promptly and efficiently.
• Participates in training and orientation of new staff as assigned.
• Engages in ongoing education and learning opportunities.
• Demonstrates commitment to cultural and emotional competence in all patient and team interactions.
• Upholds New Day Healthcare's mission and values in all patient and community interactions.