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Wellforce PHO Transition Navigator in Woburn, Massachusetts

POSITION SUMMARY : PHO Transition Navigator will work with the patient, patient’s family or caregiver, hospital team members, PCP, home care providers, elder services and PHO Care Management team to facilitate transitions of care to home and ensure adequate community supports. The Transition Navigator will focus on working with identified high risk patients and will engage with patients in the Emergency Department and inpatient units at Melrose Wakefield Healthcare. The Transition Navigator will ensure high risk patients have adequate supports prior to discharge to reduce potentially avoidable Emergency Department visits and hospital readmissions. The Transition Navigator will provide education to patients on community resources, available services, Hallmark Health PHO Preferred SNF list and will schedule follow-up PCP and/or Specialist appointments. The Transition Navigator position will improve quality of care, promote decreased length of stay and cost-effective medical outcomes and continuity of care across the continuum of care.

Education: Bachelor’s degree in Social Work or a related field preferred.

Experience: Two to three years of experience in a clinical setting required (Nursing Unit, Care Management Department, Managed Care setting, PCP office, home care or elder services) Community Health Worker with two-three years of experience will be considered.

Knowledge and Skills:

    • Ability to be a self-starter, and work independently
  • Ability to be flexible and be able to adapt to and work effectively in a medical environment

  • Ability to work well with people of various ages, backgrounds, ethnicities, and life experiences

  • Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment

  • Demonstrates effective communication skills

  • Demonstrate customer focus interpersonal skills to interact effectively with providers and with an interdisciplinary healthcare team, community agencies, patients and families

  • Ability to prioritize and resolve critical issues efficiently and effectively

  • Detail oriented, with strong organizational skills and multi-tasking abilities

  • General computer knowledge and ability to use computers required

  • Very strong working knowledge and proficiency with technology and business software (Microsoft Office)

  • Must have reliable transportation for local travel and a valid driver’s license

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