Solid Organ Transplant Navigator (Assistant Director, Community Affairs), Population Health

Empower Every New Yorker - Without Exception - to Live the Healthiest Life Possible

NYC Health + Hospitals is the largest public health care system in the United States. We provide essential outpatient, inpatient and home-based services to more than one million New Yorkers every year across the city's five boroughs. Our large health system consists of ambulatory centers, acute care centers, post-acute care/long-term care, rehabilitation programs, Home Care, and Correctional Health Services. Our diverse workforce is uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible.

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Job Description

Under supervision of the Office of Ambulatory Care and Population Health, works with Central Office (CO) Equity & Access staff and facility leadership in nephrology and gastroenterology (GI) to facilitate timely and coordinated access to solid-organ transplant services. The Navigator will be responsible for developing collaborative relationships within and outside of NYC Health + Hospitals to address patient needs; and developing service models to successfully support patients who are candidates for organ transplants. We are seeking a highly motivated self-starter who has experience with patient navigation. This role is in-person and will work at different hospital sites within our health system. Specifically, the Navigator is responsible for: proactive outreach to patients identified by providers as potential transplant candidates; patient education about the evaluation and waitlist process generally, as well as about which transplant center may be most appropriate for them (i.e., based on accessibility and geographic proximity); and, regularly scheduled meetings with the staff of partnering transplant centers to review the status of H+H patients referred for transplant to ensure that they move through the evaluation and wait-listing process in a timely manner.

General tasks and responsibilities will include:

• Works with CO, nephrology, and GI staff to pilot and refine a model ensuring that patients who may be candidates for transplant are connected to appropriate transplant centers in a timely and coordinated way. Specifically:
  • Using structured data from nephrology clinic encounters, develops a roster system for identifying, monitoring, and outreaching to potential kidney transplant candidates
  • Makes follow-up phone calls to patients to ensure completion of testing for any phase of transplantation (evaluation, waitlist, post-transplant for recipients or donor evaluation and post-donation care).
  • Conducts education sessions with nephrology providers and clinic staff to raise awareness about the Navigator role, and to encourage more widespread use of the nephrology note template that collects data on transplant access
  • Conducts education sessions with GI providers and clinic staff to raise awareness about the Navigator role, and to explore development of a GI note template that collects data on liver transplant access
• With staff from CO, nephrology, GI, and partnering transplant centers, develops patient education about the transplant evaluation, waitlist, and living donation processes, and about what to expect from transplant centers.
• Partners with local transplant centers to:
  
  • Serve as first point of contact for transplant centers' staff
  • Meet routinely (approximately monthly) with each transplant center's coordinator to review roster of H+H patients pursuing transplant there, identify barriers to transplant, and troubleshoot solutions
  • Assist with locating patients who are still in evaluation and have missed appointments, or who are high on the wait list and need to be seen by the transplant center
• When it is appropriate (i.e., given patient preference) for certain transplant-related workups, such as colonoscopy and left-heart catheterization, to occur at H+H rather than at the transplant center, works with facility staff to coordinate these workups. Ensures that patients with workups scheduled at H+H have the appropriate education, preparation and transport for the procedure.
  
  • Partners with NYLAG lawyers to address issues related to documentation status and insurance coverage. Specifically:
• Provides education to nephrology and GI clinic staff to raise awareness about pathways to transplant for patients with undocumented immigration status
• Facilitates LegalHealth appointments (expedited when appropriate) for potential transplant candidates who may face immigration and insurance barriers
  
  • Works with CO staff to optimize the transplant navigator model and set best practices for the system. Identifies opportunities to grow the navigator program over time.
• Identifies and reports patterns of inefficiency and partners with clinical and administrative staff to implement process improvements needed to alleviate future delays.
  
  • Participates in the planning, organization and implementation of the transplant navigation program. Collects, evaluates, and reports information about patient needs regarding the transplant process; communicates findings to appropriate departments for necessary action.
  • Works with CO staff to complete quarterly activity report that includes targeted, completed, and upcoming initiatives to facilitate access to transplant.
  • Other duties as assigned

Minimum Qualifications
1. A Baccalaureate degree from an accredited college or university with a major in Social Science, Social Work, Public Health or related discipline and three (3) years of full-time, progressively responsible experience in the field of community relations, community organization, public health and/or social services in a public or private social or health agency; or
2. A satisfactory equivalent combination of training, education and/or experience. However, all candidates must have minimum of a four-year high school diploma or its educational equivalent approved by a State's Department of Education or a recognized accrediting agency.

Department Preferences

Knowledge, Skills, Abilities and other Requirements:

• Patient navigation/case management
• Project management methodologies and/or organizational skills
• Electronic medical record systems, preferably Epic.
• Data organization software (e.g. Excel)
• Presentation/training software (e.g. Powerpoint)
• Strong interpersonal skills, communication skills, both in-person and remote; relationship building and working across departments and across healthcare systems.
• Ability to be pro-active and self-motivated with a passion for health equity and ensuring access to healthcare for underserved populations.
• Highly organized with project management experience.
• Experience with conducting patient outreach
• Ability to adapt to new systems and tackle novel problems creatively.
• Excellent computer skills particularly related to Cisco WebEx and Microsoft applications including PowerPoint, Excel, Word, Project, and Outlook.
• Comfort with Epic EHR system, including ability to interpret data from clinical and financial systems.
• Familiarity with issues related to the social determinants of health, safety net healthcare systems, kidney disease and dialysis, liver disease, and transplant

If applying online, please include your cover letter in the same file attachment with your uploaded resume.

NYC Health and Hospitals offers a competitive benefits package that includes:

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
• Retirement Savings and Pension Plans
• Loan Forgiveness Programs for eligible employees
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
• College tuition discounts and professional development opportunities
• Multiple employee discounts programs