Job Information
Hackensack Meridian Health Navigator, Transitions of Care in Edison, New Jersey
Overview
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, Tranistions 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.
Responsibilities
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 Transitionsof Care (TOC) program. All eligible patients will be enrolled.
Meets directly with patient/family to assess needs and develop an individualized needs assessment toplan in collaboration with the Transitions Assistant.
Facilitates communication and coordination between members of the health care team and involves thepatient/family in the decision making process, in order to minimize fragmentation of services, manageresources and remove barriers to the discharge plan of care.
Develops a TOC plan, in collaboration with the patient/family, patient caregiver, patient support personsand healthcare team that will provide maximum benefit for each patient. In addition to aligning withpatient quality metrics. Confirms the patient has a primary care provider, OB-Gyn or Behavioral Healthproviders upon discharge and refers appropriately to an FQHC or Provider that accepts patients medicalinsurance.
Participates in Multidisciplinary Team Rounds, specific to the assigned unit. Brings forth issues whichimpact patient's discharge as well as the risk of readmission to the team, for discussion and resolutionwith patient's health care team and Transitions Assistant.
Works collaboratively with all members of the multidisciplinary health care team and communitypartners 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 thosecommunity resources which will enhance patient's life and clinical outcomes. Consults with othercommunity 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 andmaximize care. The Electronic Health Record will reflect the needs of the patient, any education neededbased on the patient's medical history, coordination of follow-up care, and referral to complex BehavioralCare services.
Provides patients and families with community resources and discharge care coordination options.
Participates actively on appropriate workgroups, 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-assessedin response to changes in patient's needs and Social Determinants of Health.
Collaborates with social work and outside agencies to support the following functions; crisisintervention, counseling support and referrals, abuse/neglect, psychosocial assessment and referrals toICMS or PACT Programs as needed.
Completes all other necessary duties with attention to detail and in a timely manner.
Collaborates with Utilization Review Nurses.
Referrals:a. Primary Care Physiciansb. Behavioral Health Providersc. HUMG Internal Medicine Clinicd. Human Dimensions Programe. Meds to Bed programf. Lyft Concierge Transportationg. Financial Assistance Officeh. HMH Quit Centeri. North Hudson Clinicsj. Medication Assistance Programsk. NowPow
Qualifications
Education, Knowledge, Skills and Abilities Required :
Bachelors degree.
Knowledge of managed care principles.
Knowledge of Quality Improvement Program - New Jersey program and its Quality Metrics.
Knowledge of health care delivery system, utilization and review and case review procedures.
Knowledge of Social Determinants of Health
Good working knowledge of benefit plans; Medicaid-HMOs, etc.
Computer skills to include Google Docs and data entry.
Delegates effectively to Transitions Assistant.
Strong organizational and problem solving skills.
Excellent oral and written communication and interpersonal skills.
Exceptional communication skills to enable communication and collaboration with physicians,patients, families and ancillary staff.
Excellent critical thinking skills.
Ability to work in a fast paced team environment.
Ability to prioritize and multitask.
Ability to make sound, independent clinical judgements and act professionally under pressure.
Demonstrate ability to provide age appropriate patient education, age appropriate written and verbalcommunication skills, cultural competency and customer service skills and health literacy.
Education, Knowledge, Skills and Abilities Preferred :
Three to five years' clinical experience.
Experience with relevant systems; Google Docs, EPIC.
Master's degree.
Licenses and Certifications Preferred :
- Certified Case Manager or Accredited Case Manager Certification.
If you feel that the above description speaks directly to your strengths and capabilities, then please apply today!
Job ID 2025-160058
Department Quality Improvement Project NJ
Site HMH Hospitals Corporation
Job Location US-NJ-Edison
Position Type Full Time with Benefits
Standard Hours Per Week 40
Shift Day
Shift Hours 8:30 a.m. - 5:00 p.m.
Weekend Work Weekends as Needed
On Call Work No On-Call Required
Holiday Work As Needed
