Transition Navigator - Per Diem

Position: Transition Navigator - Per Diem

Job ID: 147689

Location: US-TX-Houston

Department: Diabetes/Endo Clinic

Talent Area: Administrative Support

Full/Part Time: Per Diem

Regular/Temporary: Regular

Shift: 8am-5pm

About Texas Children's Hospital

Since 1954, Texas Children’s has been leading the charge in patient care, education and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades such as being consistently ranked as the best children’s hospital in Texas, and among the top in the nation by U.S.News & World Report as well as recognition from Houston Business Journal as one of this city’s Best Places to Work for ten consecutive years.   Texas Children’s comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Center for pediatric research; Texas Children’s Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children’s Hospital West Campus, a community hospital in suburban West Houston; and Texas Children’s Hospital The Woodlands, the first hospital devoted to children’s care for communities north of Houston. We have also created the nation’s first HMO for children, established the largest pediatric primary care network in the country and a global health program that is channeling care to children and women all over the world. Texas Children’s Hospital is also academically affiliated with Baylor College of Medicine, one of the largest, most diverse and successful pediatric programs in the nation.   To join our community of 13,000 dedicated team members, visit for career opportunities. You can also learn more about our amazing culture at  


We are searching for a Transition Navigator – someone who works well in a fast-paced setting. In this position, you’ll be responsible for routinely meeting and leading adolescents and young adults with medical complexities and their families through the three stages of transition from pediatric to adult care (readiness, handoff, and transfer). This role will primarily be responsible for working with the care team to ensure that the appropriate members of the care team teach adolescents and young adults and their families skills important for self-managing a complex chronic illness and proactively navigating a healthcare system as adults.  A passion for working with patients with diabetes is a plus!


Think you’ve got what it takes?

Responsibilities :

  • Assesses and documents transition readiness with clinic patients starting at age 13, using a battery of measures of transition readiness skills and attitudes
  • Creates an individualized transition preparation plan with each patient and family that outlines the patient/family’s transition preparation goals for the upcoming year in the context of developmentally appropriate competencies for self-management; this plan will be shared with the patient and his/her family, care provider(s), educator(s), and other members of the team
  • Assists in implementing the transition curriculum developed by the team based on local and national recommendations
  • Creates and maintains transition registry to track patients as they progress through the stages of readiness, handoff and transfer
  • Assists with planning and participates in transition education events
  • Meets with patients and their families during the Handoff stage, at least annually
  • Discusses with each patient and family the options for adult care providers/settings based on patient preferences and medical needs, as well as anticipated residence, using a pool of adult providers
  • Develops care plan to provide to the new adult provider with input from the patient and the care team
  • Shares care plan and medical records with the new adult provider, using templates provided through EPIC/Transition Planning Tool and adapted for the section
  • Follows up by email/telephone with patient and adult provider after initial adult appointment in order to assure patient transferred to adult care and is satisfied with transfer process
  • Maintains transition registry with documentation of details of transfer to adult care


  • Bachelor’s degree in Social Work, Psychology, Human Service, Education, Communications, Pre-Med, or related Allied Health
  • Knowledge of patient population served - Endocrinology/Diabetes
  • Ability to communicate with teenagers and young adults as well as their family, and with medical professional colleagues
  • Excellent verbal and written skills
  • Ability to operate a personal computer, word processing programs, fax machine, photocopier, and multi-line telephone
  • Excellent customer service skills, advanced communication and interpretation skills with all levels of internal and external customers
  • Ability to speak proficiently in English and Spanish is preferred

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