St. John's Episcopal Hospital is recruiting for a Patient Navigator/ COS, to be a part of  The Transition of Care Team (TOC) and works along with the team to manage complex high risk patients.  The team develops and maintains a trusting relationship with the patient and caregiver. They counsel and coach the identified patients that need support and assistance to navigate the health care systems. The goal is to promote healthy lifestyle, improved health literacy and independence with self management in the community.  The COS works under the direction of the TOC RN 

Responsibilities include, but are not limited to:

·        Respond to referrals around services for patients in the  TOC Scope of services.

·         Manage TOC Center for incoming calls.

·         Conducts follow up telephone calls on high risk patients within 24-48 hours post discharge.

·         Maintain log of calls and outcomes.

·         Triage calls to appropriate team members for follow up.

·         Attend daily team huddles with TOC team to review discharge/ Transition plan for the high risk patients.

·         Serve as conduit between patients, caregivers and the hospital.

·        Coordinate services within and outside the hospital and greater community.

·        Identify any barriers to patients’ life plan or health care access and seek resolutions. Assist with removing barriers and elicit team involvement/support as indicated.

·        Home community visit based on client needs 

·        Document patient/caregiver encounters and activities on behalf of patient with outcomes.

·        Collaborate with patient/caregiver, TOC members and support networks to foster patient compliance, improve health literacy and promote healthy life style.

•      Bachelors in Health Care related Degree required

•     NYS Drivers License with travel requirements.

Professional experience working in a health care setting interacting with clinical teams

·        Work experience in health care setting with knowledge of health care terminology and processes. 

·        Knowledge of community resources

·        Excellent phone etiquette and customer relations skills

·        Effective written and oral communication skills.

·         Able to Problem solve strong attention to detail.

·        Computer skills: Word, Excel and ability to master Midas and Meditech.

·        Ability to plan and work independently as well as to enhance work of a team.

·        Knowledge of and interest in people served by hospital, the neighborhood in which they reside and  the agencies that support their activities.

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