TOC Care Navigator

• Assessment

• Triage member to identify medical, psychological, and social barriers to discharge then transition member to appropriate healthcare professional on their team such as TCN or CHW.

• Care Transition Collaboration

• Work with healthcare team to ensure safe and smooth member transitions

• Education

• Inform members and families about appointments and other care plan requirements.

• Follow-Up Coordination

• Schedule and monitor follow-up appointments with providers and community services.

• Post-Discharge Follow-Up

• Track member progress and address needs through calls following call cadence

• Refers to TCN for medical needs and CHW for community needs.

• Performs all other miscellaneous responsibilities and duties as assigned or directed.

#LI-Hybrid

• Associate's degree and two years related work experience; or equivalent combination of education and work experience.
• Demonstrated proficiency in both verbal and written communication.
• Familiarity with an extensive range of community resources, social services, and support systems (such as housing, income assistance, and legal aid).
• Strong dedication to maintaining member confidentiality while strictly adhering to relevant legal and ethical standards.
• Basic working knowledge with Microsoft Office (Word, Excel, Outlook).
• Reliable home internet.
• Must possess reliable transportation for attendance at in-person (face-to-face) meetings.

Hybrid Work Environment - Must reside on Oahu

Pay Range: $42,000 - $78,000

Note: Individuals typically begin between the minimum to middle of the pay range

The Transitions of Care (TOC) Care Navigator's primary role is to support members transitioning from hospital to home by identifying medical, psychological, and social barriers and connecting them to appropriate healthcare professionals. They coordinate post-discharge care in collaboration with Transition Care Nurses (TCNs), Community Health Workers (CHWs), and other providers to prevent readmissions through resource access, individualized care plans, and timely interventions.

Responsibilities include educating members and families on follow-up care, organizing appointments, and ensuring adherence to discharge instructions. When new or complex needs arise, the TOC Care Navigator refers members to specialized providers. Serving as a central point of contact, they help members navigate the healthcare system, reduce barriers, and promote long-term wellness.