Transition Care Manager (RN)

About Us:

Navvis is a leading population health company driving performance in value-based care. As an operating partner to some of the countrys most innovative health systems physician enterprises and health plans we provide solutions that accelerate the journey to value-based care. Our approach is market-based we respect the unique needs of populations in each community including access to care culture values and capabilities. Together with our partners we set a new national standard in healthcare performance that delivers the affordability quality access and experience that all patients deserve.

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Role Overview:

The Episode Coordinator serves as a critical component for the TEAM model. This coordinator will support patients leading up to and including the duration of the clinical episode. This individual will be the care management expert that completes regularly scheduled assessments proactively engages the patients and aligns community resources to ensure the best outcomes for the patient. The Coordinator reports directly to the Director of Clinical Transformation ensuring strong alignment but will work across care continuum lines always with the patient experience at the center.

As a Transition Care Manager:

• Manage patients attributed to CMS TEAM Episode to support optimized outcomes
• Attend hospital discharge planning meetings as needed to ensure post-discharge needs are addressed and patients are discharged to appropriate next sites of care
• Engage with patients including confirming contact information and document information about patient situation (home stairs lives alone transportation PCP and specialist) and anticipated health related needs
• Complete regular outreaches to monitor patient progression through surgical recovery identify readmission risks and work to resolve
• Serve as day-to-day partner to care management leaders across hospital and physician office sites in compliance with HMH Population Health and HMH ACO/CIN policies
• Participate in Physician Performance report outs with facility Physician Advisor and at quarterly hospital meetings
• Support the Director of Clinical Transformation and ongoing process improvement by developing and delivering case presentations and education to hospital teams
• Ensure escalation of cases to Physician Advisors in cases of disposition disconnect between Episode Coordinator recommendation and Discharge Planners Physical Therapist or Hospitalists plans

Episode Coordinator will cover these locations:

o Hackensack University Medical Center

o Palisades Medical Center (Safety Net)

o JFK University Medical Center

o Raritan Bay Medical Center

o Jersey Shore University Medical Center

o Bayshore Medical Center

o Riverview Medical Center

o Ocean University Medical Center

o Southern Ocean Medical Center

What Success Looks Like in this Role:

• Patients experience seamless transitions across the care continuum with their needs proactively identified and addressed before during and after clinical episodes.
• Regular patient assessments and outreach are completed on schedule with risks for readmission or complications identified early and mitigated.
• Discharge planning is consistently coordinated ensuring patients are discharged to the most appropriate next site of care with all post-discharge needs addressed.

We are excited about you if you have these things:

RN required

Bachelors in Nursing prepared required

3 years experience in episode care management.

Experience with value-based care management models such as BPCI CJR ACO

What youll get:

Navvis is committed to attracting the most insightful and motivated talent by providing a candidate and onboarding experience that you wont find elsewhere! We foster an environment and culture that allow people to be creative feel connected and be inspired to do their best work no matter where they are on the map. For all colleagues at Navvis we strive to ensure that they have everything needed to be successful. From the basics like a competitive total rewards strategy volunteering and social engagement activities to creating company experiences that challenge you to think differently and do different things as part of our never stop learning ecosystem we support the whole person when you become a team member at Navvis.

Navvis offers a competitive benefits package including but not limited to medical dental vision 401K with a safe harbor contribution and Paid Time Off plan starting at 2 weeks.

Our Commitment:

Navvis is an equal employment opportunity and affirmative action employer seeking diversity in qualified applicants for employment. All applicants will receive consideration for employment without regard to race ethnicity color gender gender identity age religion creed national origin ancestry disability perceived disability medical condition genetic information military or veteran status sexual orientation or any other protected status as defined by applicable law. Prior to the next step in the recruiting process we welcome you to inform us confidentially if you may require any special accommodation to complete your application and participate fully in our recruitment experience. Contact us at

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