Transition Navigator- Fresno

Location

Location: Fresno, CA (Onsite)

Classification: Full-Time

Schedule: Monday-Friday 8am-5pm

• Medical
• Dental
• Vision
• Paid Time Off (PTO)
• Floating Holiday
• Simple IRA Plan with a 3% Employer Contribution
• Employer Paid Life Insurance
• Employee Assistance Program

The initial pay range for this position upon commencement of employment is projected to fall between $20.50 and $25.62. However, the offered base pay may be subject to adjustments based on various individualized factors, such as the candidate’s relevant knowledge, skills, and experience. We believe that exceptional talent deserves exceptional rewards. As a committed and forward-thinking organization, we offer competitive compensation packages designed to attract and retain top candidates like you.

The Transition Navigator is responsible for screening, outreach, and assisting with enrollment of potential ECM members in the Hospital Setting. Outreach efforts include telephonic outreach and in-person interaction with patients in the Hospital. In addition, the Transition Navigator will help reduce the use of emergency departments for non-emergent reasons. The navigator will achieve streamlined patient care transitions and redirection to appropriate levels of care utilizing hospital and community resources to effectively educate and empower patients and their families.

The staff is responsible for keeping detailed records of their efforts and communicating regularly with their direct supervisor. The staff will work closely with Hospital’s staff throughout the hospital’s units, emergency departments, and stakeholders to facilitate member enrollment into the ECM program and help reduce avoidable ED visits. The ECM Program addresses the clinical and non-clinical needs of members with the most complex medical and social needs through systematic coordination of services and comprehensive care management.

ECM is intended to service those with chronic health conditions, are homeless or at‑risk, with high hospital admissions, substance abuse, and/or behavioral health needs. This position requires strong interpersonal and organizational skills to build rapport with members, coordinate referrals, and care amongst various healthcare providers and community services. The Transition Navigator also works with the members’ inter‑disciplinary team (ICT) supporting the members, while engaging in the member and their support systems to define priorities that are central to the member’s desired needs and goals.

• Conduct outreach and enrollment activities, including performing both in‑person and on the phone outreach to eligible and existing members to promote program enrollment.
• Educate members on ECM Program benefits and services to promote program enrollment.
• Verbalize program enrollment benefits in a clear and engaging manner, leading to increased member enrollment.
• Complete member questionnaires or assessments and consistently document care management activities and encounters in the CM System, per program protocol.
• Work collaboratively and assist clinical and social services Case Managers with care coordination, member follow‑up, communication with appropriate agencies and preparation and distribution of documents and/or reports.
• Work collaboratively and assist the Clinical or Social Services Case Managers to manage members in need of Transitional Care Services (TCS).
• Gather clinical information and assist with coordinating post‑discharge services, including scheduling provider appointments or transition of care clinic appointment, ensuring post‑discharge referrals are received by the member, transportation to appointments is arranged, and members are aware of follow‑care needs.
• Proactively initiate care transition coordination with referral sources and internal partners to ensure seamless patient transitions to home or community.
• Report on variances and issues to nursing or social services staff assigned to the members.
• Assist members with appointment scheduling, transportation, referral coordination, and other enhanced care coordination services.
• Responsible for gathering clinical…