Community Health Navigation Group LLC is a New Jersey-based minority-owned healthcare services firm specializing in Medicaid and Medicare member outreach, post-discharge care coordination, and hospital readmission reduction — backed by 19 years of documented clinical outcomes at the Northeast's most prestigious academic health systems.
The North Star has always been the same — keep that patient out of the hospital for 30 days post-discharge. Everything we do is built around that one goal.
Community Health Navigation Group LLC was not built in a boardroom. It was built inside the emergency rooms, oncology wards, and population health departments of the Northeast's most complex academic health systems.
Our founder Billy Dalia spent 19 years embedded within flagship NYC health systems as an Associate Director of Market Access — developing and implementing outreach programs that reduced 30-day readmission rates and generated millions of dollars in savings for Medicaid and Medicare payers.
That experience — managing 400 to 700 high-complexity patients annually across oncology, gastroenterology, pulmonology, and multi-comorbidity populations — is now available to Medicaid and Medicare programs, managed care organizations, prime contractors, and FQHCs through a dedicated, accountable subcontracting partnership.
We provide the human execution layer that turns population health data into measurable patient outcomes — reducing avoidable readmissions and improving quality metrics for your program.
Clinical outreach within 24-48 hours of hospital discharge for your highest-risk members — the critical window that determines whether a patient returns to the ER within 30 days.
High-touch, culturally competent engagement for Medicaid populations — appointment scheduling, medication compliance, treatment adherence, and community resource linkage.
Ongoing coordination for members with two or more chronic conditions — diabetes, cardiovascular disease, COPD, renal disease, and complex oncology and GI populations.
Systematic identification and engagement of high-risk members before readmission occurs — backed by 19 years of documented outcomes generating millions in payer savings.
Dual engagement of both patient and caregiver — the approach most outreach programs miss and the single greatest driver of sustained treatment compliance and readmission prevention.
Validated social determinants of health screening with direct community resource referral for housing, nutrition, transportation, and social support needs across NJ and NYC.
Most outreach vendors follow a script. Our team has real clinical conversations — built from years inside hospital environments managing the most complex patient populations in healthcare.
Bladder cancer, prostate cancer, lung cancer, multiple myeloma — post-discharge coordination and treatment adherence for the highest-cost cancer populations.
COPD, post-pneumonia, respiratory disease management, and lung cancer coordination — reducing avoidable readmissions for chronic respiratory populations.
IBD, Crohn's disease, hepatic conditions, GI malignancies — medication adherence and specialist follow-up coordination for complex GI populations.
High-acuity post-discharge coordination, frequent utilizer programs, and complex acute care follow-up — stopping the revolving ER door before it starts.
CHF, post-MI coordination, hypertension management — targeting the highest-volume readmission diagnosis driving payer costs across Medicaid and Medicare.
Mental health and substance use disorder care coordination — connecting high-risk members to treatment, community resources, and ongoing support services.
Diabetes management, medication adherence, A1C monitoring coordination, and chronic disease self-management support for high-risk Medicaid populations.
Complex coordination for members enrolled in both Medicare and Medicaid — the highest-need, highest-cost population in the entire healthcare system.
Our leadership spent 19 years generating documented, measurable outcomes at the most complex academic health systems in the Northeast. This is not theoretical — it is a track record built over nearly two decades of hands-on clinical program management.
When payers and prime contractors partner with Community Health Navigation Group LLC they are not getting a startup with a good pitch. They are getting a proven methodology, a clinical team with real hospital experience, and a founder personally accountable for every outcome.
A team of five healthcare professionals with direct hospital experience — not generalists. ER nurses, oncology coordinators, and specialty navigators who know what a 30-day readmission looks like before it happens.
We are available to deploy within 2-3 weeks of contract execution. Whether you are a prime contractor, managed care organization, FQHC, or government agency — we want to hear from you.
Tell us about your program and we will follow up within 24 hours.