Social Worker Transitional Navigator (NCCN) - Davie/Davidson Counties | HR 322600 B

Wake Forest Baptist Health
Job Title: Social Worker Transitional Navigator (NCCN) - Davie/Davidson Counties
Job ID: 5259
Full/Part Time: Full-Time
Regular/Temporary: Regular
Job Category: Allied Health-Clinical
Winston-Salem, NCAllied Health-Clinical, Medical, Healthcare12/13/2013The Transitional Navigator serves as an ongoing resource for post-discharged Medicare beneficiaries enrolled in the Community-based Transition Program (CCTP). The navigator''''s role is to closely monitor patients'''' adherence to treatment and followup appointments, to watch for signs that...

Job Description


The Transitional Navigator serves as an ongoing resource for post-discharged Medicare beneficiaries enrolled in the Community-based Transition Program (CCTP). The navigator's role is to closely monitor patients' adherence to treatment and followup appointments, to watch for signs that could lead to complications and/or rehospitalizations, and to educate patients and their caregivers about care and services available in our community to support aging in place and independence.

Master's in Social Work required. Three years of relevant experience and two years of experience in care of targeted patient population desired. Experience in a broad range of clinical situations and settings preferred.

Job Description
Job Title: Transitional Navigator
Department: Northwest Community Care Network
Classification: Exempt

Job Summary
The Transitional Navigator serves as an ongoing resource for post-discharged Medicare beneficiaries enrolled in the Community-based Transition Program (CCTP). The navigator's role is to closely monitor patients? adherence to treatment and followup appointments, to watch for signs that could lead to complications and/or rehospitalizations, and to educate patients and their caregivers about care and services available in our community to support aging in place and independence.

Job Relationships
Responsible to: Project Director, Northwest Care Transitions PAC
Assignments received from: Northwest Care Transitions PAC/Wake
Forest Baptist Medical Center Care Coordination Director
Positions supervised: None

Education and formal training: Master's prepared Social Worker currently licensed in the state of North Carolina.
Work experience: Three - Five years of social work experience; two years of experience in care of targeted patient population; experience in a broad range of clinical situations / settings.
Qualifications are the minimum necessary to adequately perform this job. However, any equivalent combination of experience, education and training which provides the necessary knowledge, skills and abilities would be acceptable, subject to any legal and/or regulatory requirements.

Core Processes and Activities
Following is a summary of the major job processes of this job. Other duties may be performed, both major and minor, which are not mentioned below. Specific activities for the Northwest Care Transitions Network may change from time to time:

1.Coordinates Patient Education and Care
Serves as a resource for patients and families during the enrollment process to the CCTP and ongoing while in the program
Communicates information regarding patient status and needs to other providers and community based organizations along the health care continuum. Collaborates with other care providers regarding how best to meet needs of patients
Coordinates enrollment process for patients entering the CCTP with Wake Forest Transitional Care Management Teams
Collaborates with community resources to provide assistance to patients/caregivers specified needs
Makes appropriate referrals for long-term support services to the Aging and Disability Resource Center (ADRC)
Coordinates access to medical and social histories to reduce duplication and assure community and medical providers are aware of continuing care needs
Provides educational information to patients/caregivers to enhance understanding of available services
Provide post discharge home visits and follow-up phone calls to CCTP Medicare beneficiaries to include medication reconciliation and appropriate assessments and screenings
Acts as a key member of the Northwest Care Transitions PAC team
Maintain knowledge/awareness of available community resources
Shows respect and consideration for patients/caregivers
Refers to appropriate social support services

2.Responsible for the Marketing of the Program Services
Provides education and updates to hospital case management, staff, and attending physicians regarding the Community-based Transition Program goals, inclusion criteria, and enrollment process
Provides education and information to community physicians
Provides education and information to community service providers
Identifies patient population to be served and recommends inclusion in program through appropriate program introduction

3.Participation in the Development of Standards
Documents and monitors metrics that reflect the course of care
Develop action plan for metrics that fall below established benchmarks
Participates in the assessment of program effectiveness, identifying needed changes, establishing action plans and identifying outcomes.
Participates in activities that contribute to the overall improvement of care for the identified population

4.Displays Commitment to Organizational Competencies
Communicates effectively, timely and in an open, honest manner
Shares knowledge and skills with colleagues and others
Recognizes, respects and shows trust in colleagues and their contributions
Identifies conflict, determines accountability for own role, and seeks resolution
Remains objective and empathetic despite personal feelings
Uses critical thinking skills to obtain best possible outcomes
Bases decisions on facts, knowledge, and standards
Supports team, system, and organizational goals
Completes assigned work comprehensively and in a timely manner
Displays consistency in the established organizational service standards&leader competencies


Additional Qualifications
Knowledge, skills and abilities required: Ability to successfully complete generic and department-specific skills validation and competency testing.

Physical requirements: S-Sedentary Work ? lifting, carrying, pushing, pulling, or otherwise moving objects, including the human body, weighing up to 10 pounds occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and /or a negligible amount of weight frequently (Frequently: activity or condition exists 1/3 to 2/3 of the time). Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Schedule: Flexible work hours (to allow for occasional weekend and evening hours.

To apply for this position, please click on the "Apply Now" button on this page. You must complete the application process and then submit your application by clicking on the "Submit" button located at the bottom of the page titled "Submit Online Application". You will receive the following message once you hit the submit button: "You have successfully submitted your job application".

Computers are available for applying within the lobby of the Human Resources Department located at 1920 West First Street, (on the corner of Miller and First Street) Winston-Salem, North Carolina 27104. You may also call our office for assistance at (336) 716-0175. Office hours are Monday-Friday, 8:00am-5:00pm.

If you are an individual with a disability and need reasonable accommodation to participate in the application process, please contact our Supervisor of Office Services by phone (336) 716-3367 or email at accommodationrequest@wakehealth.edu.

It is the policy of Wake Forest Baptist Medical Center to administer all educational and employment activities without discrimination because of race, sex, age, religion, national origin, disability, sexual orientation or veteran status (except where sex is a bona fide occupational qualification or a statutory requirement) in accordance with all local, state, national laws, executive orders, regulations, and guidelines.



Quick Reference

Featured Jobs

Staff Nurse II Neuro ICU 5 C

Full-Time | Regular

Physical Therapist Assistant - Acute Care

Full-Time | Regular

Ways to Give
USNWR 2013-2014Magnet Hospital RecognitionConsumer Choice2014 Best DoctorsJoint Commission Report

Disclaimer: The information on this website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider.