Care Transition Navigator/Medical Assistant
The Care Transition Navigator actively monitors transition of care events from such as admission/readmission to the hospital, skilled nursing facility admissions and planned inpatient procedures/surgeries.
1. Collaborates on patient care needs with PCP offices and the Care Coordinators/Case Managers.
2. Coordinates the integration of care transition management functions into the discharge, and home planning processes with hospital departments, external service organizations, agencies and healthcare facilities.
3. Follows the transition of care for both the acute and chronic patient populations.
4. Conducts concurrent medical record review using specific indicators and criteria as approved by medical staff, JCAHO, CMS, other state agencies.
5. Acts as patient advocate. Enhances a collaborative relationship to maximize the patient's and family's ability to make informed decisions.
6. Conducts general, elective procedure and transition of care outreach
7. Promotes effective and efficient utilization of clinical resources through consultation with their assigned health plan Case Management partner and assists the health plan with information to facilitate the care transition.
8. Mobilizes resources as needed, to achieve expected goal to assist in achieving desired clinical outcomes within the desired timeframe.
9. Conducts review for appropriate utilization of services from admission through discharge.
10. Introduces self to patient and family and explains the Care Transition Navigator role, and process for patient and family to contact the Care Coordination Department.
11. Collaborates with clinical staff in the development and execution of the plan of care, and achievement of goals.
12. Assists with outreach on gaps in care as necessary.
13. Communicates Case Management referrals to the appropriate health plan.
1. Ability to ambulate.
2. Ability to communicate by phone using standard telephone equipment.
3. Ability to communicate verbally and in writing.
4. Ability to lift up to 50 lbs. and assist with patient transfer from wheelchair to table.
5. Ability to visually assess patients and equipment.
Education & Experience Requirements
1. High School Diploma
2. Registered, certified or completion of an accredited Medical Assistant training program.
Required tasks routinely involve a potential for mucous membranes or skin contact with blood, body fluids, tissues or potential spills or splashes. Use of appropriate measures is required for every health care provider in this position.
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