<p>Community Health Navigator (CHN) - Transition of Care Program (New Jersey)</p> <p>Department: Operations</p> <p>Reports To: Program Manager</p> <p>Location: Field-Based (Hospital and Community Settings)</p> <p>Employment Type: Full-Time</p> <p>Travel Requirement: This is a field-based position requiring daily travel to hospitals, members' homes, and community settings.</p> <p>About MedZed</p> <p>MedZed delivers value-based, technology-enabled social support to high-cost Medicaid members who have been unreachable with telephonic outreach, disconnected from primary care, and using hospital-based services as their primary point of care. We combine innovative technologies with field-based outreach to engage members, reconnect them to primary care, address Health-Related Social Needs (HRSNs), and empower them to take greater control of their healthcare. Our interventions reduce Emergency Department and Inpatient utilization while improving quality of life.</p> <p>Primary Focus</p> <p>Support members during the critical transition from hospital to home and community-based care, reducing avoidable readmissions and improving care coordination by addressing both medical and social needs.</p> <p>Position Overview</p> <p>The CHN engages members during inpatient stays and continues support after discharge through home and community visits. In collaboration with the internal RN clinical team, the CHN assists with discharge planning, reinforces clinical guidance, supports medication reconciliation, and ensures members understand discharge instructions and follow-up care. Member consent must be obtained prior to enrollment.</p> <p>Key Responsibilities</p> <ul> <li>Visit members during inpatient stays to support discharge planning. </li><li>Conduct post-discharge home and community visits. </li><li>Collaborate with RN clinical team to coordinate care and medication reconciliation. Confirm inpatient status and track daily census updates. </li><li>Address social determinants of health including housing, food, transportation, and behavioral health needs. </li><li>Support appointment scheduling and completion. Maintain caseload of 35-55 members. </li><li>See 8-10 members daily across hospital and community settings. Order medical supplies as needed. </li><li>Document all encounters daily in the designated system. Escalate complex or high-risk cases appropriately. </li><li>Participate in case conferences and quality improvement initiatives. </li></ul> <p>Qualifications</p> <ul> <li>High school diploma or equivalent required; associate or bachelor's degree preferred. </li><li>Experience as a Community Health Worker, Medical Assistant, or similar role preferred. </li><li>Highly desired CNA, CMA, LPN, Home Health Aide </li><li>Experience in Case Management. </li><li>Experience in hospital settings or care coordination programs a plus. </li><li>Strong communication, motivational interviewing, and problem-solving skills. </li><li>Comfortable working in hospital and community environments. </li><li>Valid driver's license, reliable transportation, and proof of insurance required. </li></ul>