<p>Position Summary: The Transition of Care Navigator plays a dual role in supporting hospitalist program operations and ensuring safe, effective transitions of care for patients post-discharge. This position serves as a critical link between inpatient providers, case management, outpatient teams, and patients to improve clinical outcomes, reduce readmissions, and enhance the patient experience. Key Responsibilities: Hospitalist Program: Serve as the primary point of contact for hospitalist team-related inquiries. Facilitate communication between hospitalists and departments such as emergency, specialty care, nursing, and case management. Maintain accurate tracking of patient census, admissions, discharges, and transfers. Ensure compliance with documentation requirements and assist with quality data collection. Support quality improvement initiatives related to inpatient care delivery. Assist with onboarding and orientation for new hospitalists. Other duties as needed. Transition of Care Navigation: Contact patients post-discharge (typically within 48#72 hours) to assess recovery, clarify discharge instructions, and identify follow-up needs. Coordinate timely follow-up appointments with primary care providers and specialists. Identify barriers to care (e.g., medication access, transportation, social needs) and connect patients with appropriate services. Collaborate with pharmacy, home health, and community resources to support discharge plans. Document all outreach and interventions in the electronic medical record (EMR). Participate in care transition improvement initiatives or pilot programs. Other duties as needed. Qualifications: Associate#s or Bachelor#s degree in healthcare administration, nursing, social work, or a related field preferred. Experience in hospital operations, care coordination, or discharge planning. Strong knowledge of community resources, post-acute care services, and insurance processes. Strong interpersonal and communication skills with both clinical teams and patients. Proficiency in EMRs (e.g., Epic, Cerner, Athena) and Microsoft Office Suite. Ability to work collaboratively in a fast-paced, patient-centered environment. Why Join Us? At Shore Physicians Group, we work hard and take pride in accomplishing our mission statement of #Treating People Well#. We are looking for employees who strive to be the best in their field and enjoy exchanging knowledge in an interactive environment. Shore Physicians Group offers a professional, enjoyable work environment, and generous benefits including: 401(k) Medical/Dental/Vision insurance Life insurance Paid time off Tuition reimbursement Certification reimbursement Referral incentive program Local community employee discounts Free Onsite Parking Additional information To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill, and/or ability required. This job description should not be construed as an exhaustive statement of duties, responsibilities or requirements, but a general description of the job. Nothing contained herein restricts the company#s rights to assign or reassign duties and responsibilities to this job at any time. Shore Physicians Group is an Equal Opportunity Employer. #</p> <p>Position Summary:</p> <p>The Transition of Care Navigator plays a dual role in supporting hospitalist program operations and ensuring safe, effective transitions of care for patients post-discharge. This position serves as a critical link between inpatient providers, case management, outpatient teams, and patients to improve clinical outcomes, reduce readmissions, and enhance the patient experience.</p> <p>Key Responsibilities:</p> <p>Hospitalist Program:</p> <ul> <li>Serve as the primary point of contact for hospitalist team-related inquiries. </li><li>Facilitate communication between hospitalists and departments such as emergency, specialty care, nursing, and case management. </li><li>Maintain accurate tracking of patient census, admissions, discharges, and transfers. </li><li>Ensure compliance with documentation requirements and assist with quality data collection. </li><li>Support quality improvement initiatives related to inpatient care delivery. </li><li>Assist with onboarding and orientation for new hospitalists. </li><li>Other duties as needed. </li></ul> <p>Transition of Care Navigation:</p> <ul> <li>Contact patients post-discharge (typically within 48-72 hours) to assess recovery, clarify discharge instructions, and identify follow-up needs. </li><li>Coordinate timely follow-up appointments with primary care providers and specialists. </li><li>Identify barriers to care (e.g., medication access, transportation, social needs) and connect patients with appropriate services. </li><li>Collaborate with pharmacy, home health, and community resources to support discharge plans. </li><li>Document all outreach and interventions in the electronic medical record (EMR). </li><li>Participate in care transition improvement initiatives or pilot programs. </li><li>Other duties as needed. </li></ul> <p>Qualifications:</p> <ul> <li>Associate's or Bachelor's degree in healthcare administration, nursing, social work, or a related field preferred. </li><li>Experience in hospital operations, care coordination, or discharge planning. </li><li>Strong knowledge of community resources, post-acute care services, and insurance processes. </li><li>Strong interpersonal and communication skills with both clinical teams and patients. </li><li>Proficiency in EMRs (e.g., Epic, Cerner, Athena) and Microsoft Office Suite. </li><li>Ability to work collaboratively in a fast-paced, patient-centered environment. </li></ul> <p>Why Join Us?</p> <p>At Shore Physicians Group, we work hard and take pride in accomplishing our mission statement of "Treating People Well". We are looking for employees who strive to be the best in their field and enjoy exchanging knowledge in an interactive environment.</p> <p>Shore Physicians Group offers a professional, enjoyable work environment, and generous benefits including:</p> <ul> <li>401(k) </li><li>Medical/Dental/Vision insurance </li><li>Life insurance </li><li>Paid time off </li><li>Tuition reimbursement </li><li>Certification reimbursement </li><li>Referral incentive program </li><li>Local community employee discounts </li><li>Free Onsite Parking </li></ul> <p>Additional information</p> <ul> <li>To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill, and/or ability required. </li><li>This job description should not be construed as an exhaustive statement of duties, responsibilities or requirements, but a general description of the job. Nothing contained herein restricts the company's rights to assign or reassign duties and responsibilities to this job at any time. </li><li>Shore Physicians Group is an Equal Opportunity Employer. </li></ul>