JourneyCare

Care Navigator

• Expand the reach and impact of clinical hospice services by identifying and securing upstream referral sources and education opportunities
• Build relationships and drive appropriate hospice care for patients across physicians, providers, and hospitals
• Build upstream-referral relationships and transition hospice referrals from physicians and other referral sources
• Serve as a hospice clinical consultant and educator for hospital and physician care teams
• Review hospital clinical documentation, EMR, and HCHB records
• Engage patients and providers to build clinical patient profiles and admission assessments
• Identify decline patterns, including frequent hospitalizations and functional deterioration
• Educate care teams on hospice appropriateness
• Identify attending and consulting providers associated with referred patients
• Provide patient assessment, eligibility, discharge education, and awareness
• Collaborate with field sales representatives on consultative meetings with external care teams
• Initiate and maintain care team workflows for patient information, clinical assessment, documentation, consultation, education planning and delivery, and internal/external meetings
• Identify trends, needs, and partnership opportunities for earlier hospice engagement
• Foster trusted relationships with external care teams to improve patient outcomes and end-of-life satisfaction
• Communicate with hospital leadership and care coordination teams
• Organize, track, and prioritize comprehensive patient reviews
• Meet productivity requirements for medical-record review and hospital/provider consultation and education
• Collaborate cross-functionally with internal hospice departments and leadership teams
• Uphold hospice policies, privacy practices, and ethical guidelines
• Represent the organization professionally in hospitals, communities, and partner interactions
• Perform other duties as assigned

Transitional Care Navigator, RN

Manager

• Ensure the team provides initial coordination of information with clients, family members, physicians, referral sources, facility staff, agency staff, and others involved in continuity of client care
• Inform referral sources, clients, family members, and physicians about response time and follow-up plans
• Inform clinical office staff of potential admissions
• Accurately document information in the client’s medical record
• Input patient information into the EMR and update it with the correct level of care
• Complete and copy necessary paperwork to prepare patient files for admission
• Complete referral intake forms, copy referral information, attach it for clinical office staff review, and scan/upload referral information for admissions clinicians
• Establish, maintain, and close patient EMR and paper charts according to regulatory and office guidelines
• Mail, fax, or email required documentation as needed
• Verify insurance coverage and collaborate to procure needed information
• Create morning and evening census reports

Transitional Care Navigator, RN

Hospice Patient Care Manager