Transition of Care Navigator-Outpatient - Summit Medical Group

Summit Medical Group is recruiting for a Transition of Care Navigator-Outpatient. This is a full-time opportunity. This position is responsible for navigating the post-acute care of patients that are at risk for poor health outcomes, frequent emergency room visits, hospital admissions, and hospital readmissions.

Examples of Duties (List does not include all duties assigned)

•  Under the supervision of the Outpatient Coordination Manager, provides support to the Care Coordination Team.


• Consult with the Outpatient Coordination Manager and seek guidance, as necessary.


• Analyze and collect ADT (Admission-Discharge-Transfer) data.


• Assign patients discharged from hospital to appropriate team members.


• Utilize tracking program/sheets to track patient discharge status as well as track assignments to team members.


• Document notification of inpatient admission and other clinical correspondence in electronic medical record (EMR).


• Facilitate the sharing of medical information across the continuum of care.


• Collaborate with Home Health agencies to ensure collaboration of care between SMG and the agency for the care, support, and education of the patient and family.


• Secure patient records from healthcare facilities.


• Conduct chart reviews, educate patients, and facilitate follow up with provider to promote completion of age-appropriate preventive care procedures.


• Act as an advocate for an individual's health care needs by identifying and communicating potential needs to the patient’s provider.


• Maintain security and privacy of patients by keeping patient care information confidential.


• Participate in required training and attend team, departmental, and organizational meetings.


• Monitor and improve quality of services provided to patients/caregivers through ongoing participation in team and departmental quality improvement activities.


• Update job knowledge by participating in educational opportunities that support the advancement of Care Coordination including care transitions.


• Participate in the orientation and training of new staff as needed.


• Transition of Care Navigator - Outpatient job description is not designed to cover or contain a comprehensive list of activities, duties, or responsibilities that are required of the employee for this position. To deliver exceptional customer experience and consistently meet the needs of SMG, additional duties responsibilities may change at any time.


• Maintains strictest confidentiality both internally and externally.


• Adheres to expectations of the established corporate compliance plan.


• Actively participates in site-level Quality Improvement Activities. Each employee will contribute to the continual evaluation site performance as well as the implementation and measurement of improvement activities that increase the quality of care provided to patients.


• Performs related work as assigned.

Education

High School diploma or equivalent required, CMA or CNA (preferred).

Experience

Minimum 1 year of experience in clinical experience with preference for those that have worked in a Primary Care setting. Will consider individuals with strong technical skills in Microsoft Excel and excellent ability to maintain databases as well as extract and analyze data from primary and secondary sources.