CARE TRANSITION NAVIGATOR 

INTEGRITY ● COMPASSION ● EXCELLENCE ● INNOVATION 

POSITION SUMMARY: 

The Care Transition Navigator (CTN) is responsible for guiding adult patients with behavioral health needs through the continuum of care as they transition from inpatient or intensive outpatient settings - such as hospitals, Assertive Community Treatment Teams (ACTT), and Intensive Outpatient Programs (IOP) - into community-based services.   

The CTN serves as a vital connector between discharging facilities and outpatient care, working to minimize therapy abandonment, reduce readmissions, and improve continuity of care.  This role involves proactive outreach, care coordination, and hands-on support to ensure patients receive timely follow-up appointments and uninterrupted access to prescribed medications.   

The CTN collaborates closely with clinical teams, pharmacies, caregivers, and community-based organizations to address barriers to care, navigate insurance and medication access challenges, and promote long-term treatment adherence.

A successful Care Transition Navigator (CTN) will possess the skills and initiative required to achieve the following key performance objectives:

• Build and maintain strong partnerships with psychiatric treatment centers, behavioral health facilities, and hospital discharge teams to ensure seamless transitions of care.
• Coordinate and manage the discharge communication process, including initiating contact with designated facility staff, engaging directly with patients and caregivers, and ensuring timely and clear correspondence with pharmacy staff to support medication access and adherence.
• Capture and support at least 90% of all eligible discharges involving patients prescribed the targeted medication, ensuring appropriate enrollment in follow-up care pathways.
• Ensure first-dose administration for at least 90% of eligible patients post-discharge by coordinating appointments, verifying insurance, and resolving access challenges.
• Convert 90% or more of first-fill patients to ongoing, long-term therapy through sustained outreach, appointment follow-ups, and medication adherence support.
• Facilitate an average of at least ten (10) discharges per week during the program’s first year by building strong site relationships and streamlining coordination efforts.

KEY RESPONSIBILITIES: 

Discharge Planning and Outreach 

• Serve as a primary liaison for patients and caregivers during the transition process.
• Initiate live contact (phone or in-person) within 48 hours prior to discharge to review care plans, confirm medication status, and identify potential barriers to post-discharge treatment.
• Collaborate with discharge coordinators, case managers, and clinicians to arrange injection scheduling post-discharge, including coordination with mobile health services when applicable.

Post-Discharge Coordination & Follow-Up 

• Within 24 hours of discharge, conduct live outreach to introduce CTN Services and collect patient information (e.g., demographics, payer information, last injection date, dose).
• Within 48 hours, facilitate insurance verification and initiate benefits investigation in collaboration with the patient, caregiver, or payer.
• Schedule follow-up appointments with outpatient clinics, mobile providers, or community mental health centers and confirm patient participation.

Insurance Navigation & Access Support 

• Triage and manage prior authorizations, including follow-up with providers and documentation support within five (5) business days.
• Provide daily updates on authorization statuses, including denials, and troubleshoot with prescribers or pharmacy staff as needed.
• Contact insurance payers to confirm pharmacy network participation and resolve out-of network access issues.
• Assist with applications for Medicaid, Medicare, or financial assistance programs such as Low-Income Subsidy (LIS) as needed to support continuity of care.

Appointment & Treatment Management 

• Conduct ongoing follow-ups to ensure continuity of treatment, including second initiation dose and maintenance dose scheduling and reminders.
• Track patient appointment attendance and manage missed appointment follow-up within one (1) business day.
• Provide post-appointment support, track refills, and ensure alignment with dosing schedules and alternate injection sites.  
• Maintain weekly injection rosters and coordinate across care teams to ensure timely administration. 

Social Determinants of Health & Community Support 

• Assess each patient’s social needs, including housing, food access, employment status, and ability to attend appointments.
• Refer to appropriate services: housing programs, peer support services, job training, phone access, and Behavioral Health Organization (BHO) resources.
• Coordinate transportation logistics, including payer-sponsored services or facility-based support.

Communication and Documentation 

• Accurately document all CTN activities, clinical interactions, and coordination efforts per guidelines and protocols.
• Share relevant updates with HCPs, discharge coordinators, outpatient teams, and community-based clinics to support shared decision-making and care planning.
• Track all outreach attempts, interactions, referrals, and outcomes in the designated internal care coordination platform in accordance with SOPs and guidelines.

QUALIFICATIONS: 

Education: 

• Associate or bachelor’s degree in human social services, social work, behavioral health, nursing, public health, pharmacy, or a related field required.  Equivalent work experience may be considered in lieu of formal education.

Experience: 

• Minimum of two (2) years’ experience in care coordination, case management, or patient advocacy preferred.  Healthcare or transitional care experience is strongly desired.
• Experience with long-acting injectable antipsychotic medications and high-risk mental health populations strongly preferred.
• Familiarity with Medicaid, Medicare, and private insurance systems, including prior authorization processes.
• Experience working across interdisciplinary care teams and community-based services is a plus.

Skills & Competencies: 

• Strong communication and interpersonal skills to work effectively with patients, caregivers, and diverse healthcare teams.
• Knowledge of behavioral health treatment systems, discharge planning practices, and social determinants of health.
• Exceptional time management, follow-through, and organizational abilities.
• Proficient in electronic health records (EHRs), pharmacy platforms, or care coordination documentation systems.
• Ability to work independently and collaboratively while managing multiple cases in a fast paced environment.

WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS: 

• Position may require travel to hospitals, behavioral health facilities, or outpatient clinics.
• Must be able to use standard office and communication equipment (e.g., phone, laptop, video conferencing tools).
• Occasional extended hours may be necessary to support patient discharges and appointment coordination.