Transitional Care Navigator Job at Arcadia Home Care and Staffing

Transitional Care Navigator

Addus Home Care / JourneyCare Hospice is seeking a Hospice Transitional Care Nav...

Location

United States , Naperville

Salary:

82000.00 - 93000.00 USD / Year

Arcadia Home Care and Staffing - an Addus family company

Expiration Date

Until further notice

Requirements

Bachelor’s degree in marketing, business administration, or other related fields is preferred
Licensed as a registered nurse in the state of practice, preferred
Minimum of two years relevant experience
Must possess the ability to make independent decisions when circumstances warrant
Must possess the ability to deal tactfully with patients, family members, visitors, agency personnel, and public
Must be knowledgeable of quality assessment and assurance procedures
Valid driver’s license and proof of insurance is required

Job Responsibility

Serve as hospice clinical consultant and educator, acting as extensions of hospital and physician care team
Review hospital clinical documentation/EMR/HCHB, engage with patients and providers to build clinical patient profiles and clinical-admission-assessments and identify decline patterns
Consult with hospital care teams by sharing clinical profiles and educating on hospice appropriateness
Identify attending and consulting providers associated with referred patients – to provide patient assessment, eligibility and discharge education and awareness
Collaborate with field sales representatives to schedule and conduct consultative meetings with external care teams
Initiate and maintain care team workflows for: Patient information / clinical assessment and documentation, Consultation / education planning and delivery, External and internal meetings and preparations
Identify trends, needs, and partnership opportunities for earlier hospice engagement
Foster effective and trusted relationships with external care teams to improve patient outcomes and enhance end-of-life satisfaction
Communicate clearly and consistently with hospital leadership and care coordination teams
Effectively organize, track and prioritize high-value patient comprehensive reviews

What we offer

Great culture and team atmosphere
Comprehensive benefits (medical, dental, vision, life/AD&D, disability), effective on the first of the month
401(k) retirement plan with a generous company match
Generous time off accruals
Paid holidays
Mileage reimbursement
Tuition Reimbursement
Employee Referral Program
Merit Increases
Employee Discount Programs

Fulltime

Rn - Transitional Care Navigator

Harrison's Hope Hospice is seeking an RN Transitional Care Navigator. This posit...

Location

United States , Meridian

Salary:

Not provided

Arcadia Home Care and Staffing - an Addus family company

Expiration Date

Until further notice

Requirements

Bachelor’s degree in marketing, business administration, or other related fields is preferred
Licensed as a registered nurse in the state of practice, a plus
Must possess the ability to make independent decisions when circumstances warrant
Must possess the ability to deal tactfully with patients, family members, visitors, agency personnel, and general public
Must be knowledgeable of quality assessment and assurance procedures
Valid driver’s license and proof of insurance is required

Job Responsibility

Collaboration with the Hospice Liaison team and Admissions team to increase public awareness of hospice and other services provided by the agency and to drive admissions for the placement of patients to meet expectations
Act as first point of contact for hospitals, health care facilities, and other sources regarding referrals
Seek networking opportunities to provide education and to develop relationships with new and existing referral sources
Identifying appropriate care and services to patient and family in accordance with attending physician and plan of care, as well as company policy and procedures

What we offer

Great culture and team atmosphere
Comprehensive benefits (medical, dental, vision, life/AD&D, disability), effective on the first of the month
401(k) retirement plan with a generous company match
Generous time off accruals
Paid holidays
Mileage reimbursement
Tuition Reimbursement
Employee Referral Program
Merit Increases
Employee Discount Programs

Transitional Care Services Community Health Worker II

The Transitional Care Services (TCS) Community Health Worker II (CHW) is respons...

Location

United States , Los Angeles

Salary:

55245.00 - 82867.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

High School Diploma/or High School Equivalency Certificate
At least 6 months of experience as a health navigator, peer support worker, outreach worker, promotora, or working in a community setting and providing health education for chronic conditions, or equivalent
Knowledge of community resources for Medi-Cal members
Comfortable working with diverse populations
Exceptional ability to connect and engage with people
Willingness to work in various environments including 1:1 in member’s homes, hospitals, skilled nursing facilities, other clinical settings, and/ or shelters
Excellent verbal and written communication skills
Detail oriented, organized and possess time management skills
Basic computer skills
Must have access to reliable transportation to carry out job-related essential functions

Job Responsibility

Promoting members’ optimal health and well-being through active engagement and helping them navigate and access health services when transitioning between care settings
Cultural Mediation Among Individuals, Communities, and Health and Social Service Systems
Providing Culturally Appropriate Health Education and Information
Care Coordination, Case Management, and System Navigation
Providing Coaching and Social Support
Advocating for Individuals and Communities
Building Individual and Community Capacity
Implementing Individual Assessments
Conducting Outreach
Perform other duties as assigned

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Ambulatory Care Navigator, Urology Oncology

Provides continuity of care by ensuring smooth transitions between care settings...

Location

United States , Winston Salem

Salary:

40.30 - 60.45 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Registered Nurse license issued by the state in which the team member practices
Bachelor's Degree in Nursing
Typically requires 5 years of experience in nursing that includes performing nursing assessments, care plan development, and educating patients
Working knowledge of the components of quality and acute patient care needs
Maintains clinical expertise to effectively manage physical, emotional, psychosocial and spiritual needs of patients throughout the care continuum
Excellent analytical and interpersonal communication skills necessary to negotiate with families, patient, physicians, and third-party payers
Demonstrated ability to work well with physicians and other professionals in a direct and positive manner

Job Responsibility

Provides continuity of care by ensuring smooth transitions between care settings
Develops a relationship with patient and their multidisciplinary team to facilitate and/or navigate through subsequent treatment and follow-up to reflect continuity of care
Completes a nursing assessment to identify the patient's individualized needs and collaborates with multidisciplinary team and other departments to develop an interdisciplinary plan of care
Supports the patient and family by providing education, addressing psychosocial needs, advocating, providing continuity of care and identifying barriers to care
Navigates patients and family members throughout the diagnosis, treatment and follow-up of the patient throughout the continuum of care
Provides expert clinical advice to the multidisciplinary team in designing collaborative teaching plans/programs and in planning/providing patient/family education and discharge planning including wellness and health maintenance within designated specialty
Coordinates timely, seamless, evidenced based care across the care continuum resulting in best patient outcomes
Evaluates, selects or designs patient education materials on specific disease site programs
Provides education and outreach programs to patients, Advocate staff and to members of the community
Assist leadership in developing program vision, goals and objectives

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Opportunity for annual increases based on performance
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions

Fulltime

Nurse Practitioner, Transitional Care

The Advanced Practice Provider, Transitions delivers high-touch, high-quality ca...

Location

United States , Indianapolis

Salary:

Not provided

CVS Health

Expiration Date

July 21, 2026

Requirements

Have an active, non-probationary state medical license, including US work authorization, if applicable
1+ years APN experience, preferably with a Medicare population
Experience in home-based care (as RN or APP) preferred
Flexibility to travel throughout service area
Electronic Medical Record experience
Computer skills: Ability to quickly navigate and use multiple computer programs to include, but not limited to: Gmail, MS Word or Google Docs, Excel or Google Sheets, etc.
Additional language proficiency in Spanish, Polish, Russian, or other languages spoken within the communities we serve preferred but not required

Job Responsibility

Provide post-discharge support according to defined pathways within the patient's home
Develop care plans and individualize goals of care with patient, their families, and their providers
Optimize and monitor clinical status, identify and address gaps in care, reconcile medications and address adherence challenges
Collaborate with Transitional Care Managers, home health, social workers, hospitals, SNFs, and specialists
Structure and prioritize scheduling based on clinical complexity for both new and routine patients
Recognize, diagnose, and manage both acute and chronic medical conditions in order to prevent destabilization and readmissions
Provide after-hours and weekend call support, shared with other in-state providers
Facilitate and conduct goals of care and advance care planning discussions with patients and families
Assess and evaluate family/caregiver needs and limitations
Teach patients, caregivers, and others about their health conditions

What we offer

Mission-focused career impacting change and measurably improving health outcomes for Medicare patients
Paid vacation, sick time, and investment/retirement 401K match options
Health insurance, vision, and dental benefits
Opportunities for leadership development and continuing education stipends
New centers and flexible work environments
Opportunities for high levels of responsibility and rapid advancement
Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Paid time off
Flexible work schedules

Fulltime

Care Coordinator RN

As our RN Care Coordinator, you will help patients navigate the healthcare conti...

Location

United States , Sacramento

Salary:

74.56 - 90.51 USD / Hour

American Nursing Care

Expiration Date

Until further notice

Requirements

Current California RN licensure
Minimum of two (2) years of acute hospital clinical experience or a Master's Degree in Case Management or Nursing field in lieu of one (1) year experience
BLS through the American Heart Association (AHA) within 90 days

Job Responsibility

Help patients navigate the healthcare continuum to achieve optimal health outcomes and a smooth transition to post-acute care
Assess, plan, facilitate, and advocate for options and services for assigned patients
Coordinate care, communicate with various stakeholders including physicians and insurers, and collaborate to ensure quality and cost-effective outcomes within the appropriate level of care

What we offer

Health/dental/vision
FSA
Matching retirement plans
Paid time off
Tuition assistance
Adoption assistance

Rn Health Coach Clinic

As our RN Health Coach you will help patients, physicians, advanced practice pro...

Location

United States , Garrison

Salary:

28.82 - 41.80 USD / Hour

American Nursing Care

Expiration Date

Until further notice

Requirements

Graduate of a Registered Nurse program
Current license as a Registered Nurse in the state of ND

Job Responsibility

Help patients, physicians, advanced practice providers, staff, and other professionals coordinate patient care across the continuum so they can achieve improved health outcomes and navigate the healthcare system effectively
Manage disease registries by identifying and following up with patients not meeting clinical goals based on evidenced-based guidelines
Serve as a liaison with specialty practices, in-patient facilities, and community resources
Work autonomously, use education, goal setting, action planning, problem-solving, and motivational interviewing to support health behavioral change
Contribute leadership to the healthcare team
Provides comprehensive patient support, assessing emotional/cognitive status and learning readiness, while also acting as a patient advocate within the healthcare system
Collaborates with primary care providers, interdisciplinary teams, and community resources to ensure continuous, high-quality care and address changing patient needs
Effectively utilizes the nursing process and disease registries for preventive maintenance and chronic disease management, identifying and addressing gaps in care
Delivers effective education to patients and their families, empowering them to meet disease-specific goals
Collaborates with internal leaders to support, implement, review, share, and submit performance metrics to enhance quality outcomes

What we offer

Medical
Prescription drug
Dental
Vision plans
Life insurance
Paid time off (full-time benefit eligible employees may receive a minimum of 14 paid time off days, including holidays annually)
Tuition reimbursement
Retirement plan benefit(s) including, but not limited to, 401(k), 403(b), and other defined benefits offerings

Parttime

Clinical Specialist, Quality Management I

Who We Are: Because health is personal. That's why Personify Health created the ...

Location

United States

Salary:

60600.00 - 91000.00 USD / Year

Personify Health

Expiration Date

Until further notice

Requirements

Active, unrestricted Registered Nurse (RN) license required
Basic computer literacy
The ability to work on multiple screens, and proficient typing skills
Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook
Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others
Ability to work independently and utilize written resources to problem solve
After training with our training department and 1.5 months ramp (3 months total), must have and be able to work in: Teams on and off camera, SharePoint, Drives as needed, VPN, UM Web or Health Notes, El Dorado, Quick Links, GIAS, ADP, Confluence, Phone system with headset, Smartsheet
Knowledge of medical claims and ICD-10, CPT, HCPCS coding
Excellent verbal and written communication skills for upward and downward conversations
Level I: In-depth knowledge of applicable regulations and accreditation standards (HIPAA, CMS requirements as applicable, NCQA, URAC)

Job Responsibility

Ensure compliance with state, federal, and accreditation requirements (e.g., HIPAA, CMS, NCQA, URAC, ERISA, as applicable)
Conduct internal and external audits of UM/CM/CDM processes and documentation
prepare audit files, findings, and corrective action recommendations
Identify quality and compliance risks and collaborate with cross-functional partners on mitigation and resolution
Review and support SOPs and workflows to ensure regulatory alignment and operational clarity
Support external audit readiness activities, including NCQA and URAC evidence preparation and maintenance
Develop, maintain, and deliver role-based training curriculum aligned to compliance standards, quality goals, and operational workflows
Conduct onboarding and orientation to prepare staff for assigned UM/CM/CDM functions
Deliver training using multiple modalities (virtual, self-paced, and one-on-one coaching) tailored to adult learners
Ensure training covers applicable processes such as case initiation and closure, documentation standards, high-dollar case monitoring, stop-loss notification, administrative support, customer service, and productivity expectations

What we offer

Competitive base salary and benefits effective day one
Comprehensive medical and dental through our own health solutions (yes, we use what we build)
Unlimited PTO—rest and recharge time is non-negotiable
Mental health support, retirement planning, and financial protection
Professional development with clear career progression and learning budgets
Mission-driven culture where diverse perspectives drive real impact on people's health

Fulltime

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Transitional Care Navigator

Job Description

Job Responsibility

Requirements

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