Navigator, Transitions of Care

Our team members are the heart of what makes us better.

At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community.

Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.

The Navigator, Transitions of Care is a member of the healthcare team and is responsible for coordinating, communicating and facilitating the care of patients with Medical, Behavioral and Maternal Health needs. The navigator is accountable for a designated case load determined by the careful daily selection of eligible patients. They assess, plan, and facilitate, with patients/families and healthcare professionals involved in the patient's care to meet treatment goals, and arrange for the appropriate next steps.

Oversees Inter facility Coordination and handoff between acute & outpatient services.

This position will be based in the Northern Region.

A day in the life of a Navigator, Transitions of Care at Hackensack Meridian Health includes:

• All patients who are admitted for medical care will be screened for potential eligibility to the Transitions of Care (TOC) program. All eligible patients will be enrolled.
• Meets directly with patient/family to assess needs and develop an individualized needs assessment to plan in collaboration with the Transitions Assistant.
• Facilitates communication and coordination between members of the health care team and involves the patient/family in the decision making process, in order to minimize fragmentation of services, manage resources and remove barriers to the discharge plan of care.
• Develops a TOC plan, in collaboration with the patient/family, patient caregiver, patient support persons and healthcare team that will provide maximum benefit for each patient. In addition to aligning with patient quality metrics. Confirms the patient has a primary care provider, OB-Gyn or Behavioral Health providers upon discharge and refers appropriately to an FQHC or Provider that accepts patients medical insurance.
• Participates in Multidisciplinary Team Rounds, specific to the assigned unit. Brings forth issues which impact patient's discharge as well as the risk of readmission to the team, for discussion and resolution with patient's health care team and Transitions Assistant.
• Works collaboratively with all members of the multidisciplinary health care team and community partners for timely and appropriate transitions to the next appropriate level of care.
• Maintains current and up to date information of community resources and refers patients to those community resources which will enhance patient's life and clinical outcomes. Consults with other community agencies and committees to identify potential resources to support patients and their families. Will actively work to find community partners
• Documents and communicates information to the Multidisciplinary Team in order to coordinate and maximize care. The Electronic Health Record will reflect the needs of the patient, any education needed based on the patient's medical history, coordination of follow-up care, and referral to complex Behavioral Care services.
• Provides patients and families with community resources and discharge care coordination options.
• Participates actively on appropriate work groups, and/or meetings. Is a positive problem solver. Identifies and refers quality issues for review to the Regional Manager.
• Reassesses periodically and evaluates against care goals and the plan of care and, when indicated, the plan or goals are revised. Medical records reflect that each patient's discharge plan is re-assessed in response to changes in patient's needs and Social Determinants of Health.
• Collaborates with social work and outside agencies to support the following functions; crisis intervention, counseling support and referrals, abuse/neglect, psychosocial assessment and referrals to ICMS or PACT Programs as needed.
• Complete…