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Emergency Department Navigator and Transition Coordinator



UNC Family Medicine Center, a patient-centered primary care practice, aims to improve and support the health of people living in the community. In addition to providing team-based primary care, UNC FM collaborates with a variety of organizations, agencies and medical providers to offer a robust set of health programs in the community. One of these community programs is Carolina Health Net (CHN), a system of care for high cost/high risk patients without a primary care medical home. The CHN priority population is the uninsured. CHN offers patients’ access to a medical home, care coordination, medications, diagnostic, and specialty services.

The Emergency Department (ED) Navigator and Transitions Coordinator (TC) will assess needs of the FMC and CHN patient populations who are transitioning from the hospital emergency department, Observations Unit, and inpatient services back to the community and primary care. The position will coordinate care and arrange for services specific to identified patient needs.To accomplish program objectives, the position will need to work with hospital and medical home staff in addition to understanding available resources in the community.

Essential Position functions:

  • Access real time emergency room and inpatient hospitalization data to identify patients potentially eligible to receive services. Also, work with FMC transitions team to identify FMC patients who are in the hospital and ready for discharge in order to complete initial transitions assessment and schedule follow-up appointment if appropriate.
  • Conduct individual patient assessments to understand more about the individual needs and goals. Link to appropriate services. E.g.Primary care, care management, and UNC pharmacy and charity care programs.
  • Document interventions in EPIC and CHN database.
  • Schedule urgent appointments for patients in Centricity and/or EPIC where option is applicable.
  • Work with supervisors to set up a system for coaching patients who have had greater than (3) three non-emergent ED visits in the past (6) six months.
  • Provide on-site interventions to include, but not limited, to education and linkage to services customized to meet the respective patient’s needs.
  • Alert FMC and/or CHN care managers about their patients who are coming to ED and any on-site interventions provided via Epic or the CHN Database.
  • Develop local resource list and referral procedures.
  • Disseminate approved educational tools
  • Maintain records for tracking and evaluation purposes where appropriate
  • Obtain training in the Stanford self-management curriculum and teach classes as assigned but at least one time a year.
  • Assist in project evaluation.
  • Provide ongoing educational and outreach activities.
  • Collaborate with inpatient, FMC, and CHN Care Managers to assure referral process is mapped and process is working well
  • Participate in CHN community collaborative meetings and ED meetings.

Essential Skills:

  • Excellent communication skills both orally and in writing
  • Considerable knowledge of care management principles
  • Knowledge of government, private organizations and community resources
  • Skill in establishing rapport with a client and applying techniques of assessing psychosocial aspects of a client’s problem
  • Knowledge of and compliance with federal and state regulations applicable to the position
  • Analytical skills necessary as independent decisions and problem solving are required
  • Strong organizational and computer skills required including various office software and Internet
  • Critical thinking skills, sound clinical judgment, and problem solving abilities

Bachelor's degree in Social Work (BSW) from a program accredited by the Council on Social Work Education. Previous related experience preferred, but not required.

Primary Location: Chapel Hill, North Carolina, United States

Department: P-31234-SOM AMB CARE-FPC-OTHER-F

Shift: Day Job