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Discharge Navigator

Milton, Massachusetts

Organization Facility: Beth Israel Deaconess Hospital Milton Category: Social Services Job ID: JR47819 Date posted: 03/25/2024
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When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Job Type:


Scheduled Hours:


Work Shift:

Day (United States of America)

Beth Israel Deaconess Milton is committed to improving the health of our community by providing exceptional, personalized health care with dignity, compassion and respect.

Beth Israel Milton is currently seeking a part-time Discharge Navigator.

The Navigator is responsible for developing, coordinating, and maintaining the care continuum for patient populations with high readmission rates, including orthopedic, CHF, and Pneumonia. Provides coordination of the continuum of care beginning before surgery, including Preadmission Testing, Peri-op Services, inpatient units, and post-acute. Assist in the planning, developing, and implementing program goals and operations. Additionally, the Navigator will be responsible for reviewing and following up on lab reports for the Emergency department seven days a week, working with the Emergency Team and PCP for escalation to ensure follow-up on any abnormal results.


Identifies patients who are admitted with Joint replacement (JR), CHF, Pneumonia

Identifies patients who are readmitted within 30 days ( JR, CHF, Pneumonia )
Monitors patients and meets with them during their hospital stay.

Uses LACE score to help identify patients at high risk for readmission 

Reviews medication lists for any discrepancies         

Call patients and families to review the implementation of care plans. Referring patients to services frequently used in a clinic and specialized services as needed.

Explain hospital/community-based resources to patients and families and provide documentation.

Assessing patients for referrals to resources. Acting as a liaison with internal and community resources. May contact hospital and community resources to ensure access to services.      

May assist patients and families with scheduling multidisciplinary appointments.

Reviewing appointment schedule and appointment instructions.

Coordinating logistics for plan adherence, such as appointment reminders and arranging transportation. 

Maintaining relationships for accessing community-based resources. Providing outreach and maintaining positive working relationships with providers/administrative staff (including physicians, office staff, nurses, and social services staff) Documenting patient care and collecting required data. Tracking outcomes and supporting strategic planning processes. Develops and maintains data.      

Attending and participating in care planning meetings to prepare patients for discharge or continuing care.  

Assess and reach out to Pre-op Joint replacement patients to ensure readiness for surgery and post-care needs, collaborate with the PAT team, including Surgeon Offices.

Identifying patients with high readmission rates identifies root causes and implementing preventive action plan.

Ensures Hospital goals of LOS reduction,  readmission prevention, and satisfaction improvement are monitored. 

Monitors patient outcomes and participates in quality improvement activities.

Daily monitors all abnormal lab results from the ED and escalation to ensure follow-up on any abnormal results.

Employee maintains competencies required for the specific patient population served.

Performs all duties in accordance with safety and other laws, rules, and regulations set forth by appropriate regulatory and government agencies and in accordance with established department and hospital policies and procedures.

May be required to perform similar or related duties as may be necessary on an emergency basis or as designated by the department manager or supervisor.

The nature of the tasks/responsibilities required of employees in this position will likely expose them to blood and body fluids. Employees will be oriented to and required to understand and follow the standard precautions for infection control.  A summary list of tasks and procedures that may cause exposure to blood and body fluids is listed in the attached Physical Abilities Job Description.  Also identified is the protective gear that is available.


Bachelor's degree required, Master's degree preferred

A minimum of 5 years of relevant experience in an acute healthcare environment. Previous experience in Nursing or Physical Therapy preferred.

Experience with computer systems required, including web-based applications and some Microsoft Office applications, which may include Outlook, Word, Excel, and PowerPoint.  

A Physical Abilities Job Description is a component of this Job Description.

The above statements are intended to describe the general nature and level of work being performed.  This list is not to be construed, as an exhaustive list of all responsibilities, duties and skills required of personnel so classified

Job Description:

FLSA Status:


As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled

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Why join Beth Israel Lahey Health?

If you’re looking for a career where you can make a difference and explore your potential, Beth Israel Lahey Health is the place you belong. Our system includes a network of hospitals, physician practices, outpatient centers, and other healthcare facilities and we offer a broad range of careers in direct patient care, environmental services, registration, finance and many other fields. We are focused on providing compassionate and personalized healthcare with a strong reputation for clinical excellence and research and offer diverse opportunities for career growth and development. Conveniently, we have many locations in communities across Eastern Massachusetts and Southern New Hampshire.

At Beth Israel Lahey Health, we see you for all that you are – your experience and your dreams. Explore our open opportunities and find out why so many have already chosen to join our team.

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Learn more about working at Beth Israel Deaconess Hospital Milton.