Transitional Care Navigator

Job Details Description

Why work for us? Interested in joining an award‑winning organization that positively impacts the lives of homecare and hospice patients? We proudly serve the community and our staff, ensuring a supportive, positive and inclusive environment, driven by our mission. Our engaging culture offers competitive pay, training, reimbursement for mileage, respect, generous benefits package, state of the art equipment and so much more.

Service Areas:
We service 25 communities in southern NH from Hooksett to Nashua. We are the preferred provider for 3 hospitals.

• Associate or bachelor’s degree in social work, healthcare, business administration, or a related field
• Minimum of one year of community/public health nursing or relevant healthcare experience

• Valid driver’s license and proof of insurance
• Current BLS certification
• Proficiency with Microsoft Office Suite

• Active New Hampshire Registered Nurse (RN) license

• Maintain a consistent presence in assigned facilities, engaging with patients, families, and key decision makers
• Respond promptly to referrals from hospitals and facilities
• Educate patients, families, and referral partners on Home Care and Hospice services
• Advocate for patients and families to ensure their needs and goals are clearly represented

• Collaborate with referral case managers to assess patient needs
• Develop a strong understanding of each patient’s clinical status, home support, and goals of care
• Request and review comprehensive clinical data for HHHC Intake and TCN teams
• Communicate safety concerns to Home Care/Hospice Managers prior to accepting referrals
• Complete TCN documentation using established templates
• Track pending referrals to ensure all required documentation is received for timely scheduling

• Communicate clinical status and decline with Hospice Manager and CHH Medical Director to determine eligibility
• Coordinate durable medical equipment and transportation as needed

• Partner with facility case managers to identify high‑risk patients
• Engage in proactive problem‑solving to support safe transitions home
• Participate in communication with inpatient and outpatient providers to identify root causes and prevent recurrence

• Participate in care coordination meetings and case conferences
• Attend regularly scheduled onsite collaborative meetings with referral partners
• Monitor facility capacity and referral trends
• Identify opportunities to strengthen preferred provider relationships

• Participate in business development team meetings
• Identify opportunities to improve processes and enhance patient outcomes
• Assess unmet needs of referral partners and identify opportunities aligned with HHHC’s mission and values

• Maintain proactive, consistent presence in assigned facilities
• Respond to referrals in a timely and professional manner
• Communicate effectively with referral partners, patients, and families
• Advocate for patient needs and goals
• Ensure complete and accurate documentation
• Collaborate with facility teams to support safe transitions and reduce rehospitalizations
• Participate in care coordination and process improvement initiatives
• Maintain regular, reliable attendance

We value diversity — in backgrounds and in experiences. Healthcare is a universal concern, and we need people from all backgrounds and swaths of life to help build the future of healthcare.

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, disability status, veteran status, or any other characteristic protected by law.