Description

Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?

Summary:

• Accountable to provide complex case management for adult patients within the Penn Medicine Princeton Health system with a readmission history. Performs administrative functions to support the coordination of outpatient care needs. Facilitates interventions aimed at reducing additional readmissions such as completing hospital avoidance care plans with patients, discussing, and completing advanced care planning documents. Community Health Navigator is responsible for connecting Penn Medicine Princeton Health patients to medical providers and community resources upon discharge and will follow patient for 90-day period post- discharge.

• Responsibilities:

1. Manage a caseload of patients to provide readmission reduction strategies to those currently in house or post-acute/home.

• Establish and maintain effective ongoing relationships by facilitating communication and coordination with members and their primary care physicians, post-acute care teams such as Homecare, ACO and post-acute care managers.

• Ensure access to follow-up health care by facilitating medical appointments.

• Discuss symptoms management for chronic illness and emergency room alternatives with patients

• Identify needs for advanced care planning and facilitate conversations and completion of documents specific to goals of care (Example: POLST, HCP).

• Document all patient interactions and follow-up interventions in EPIC.

• Help clients in utilizing resources, including scheduling appointments, and assisting with completion of applications for programs for which they may be eligible.

• Facilitate patient engagement in routine preventive screenings through PCP, community programs or Clinic.

• Advise patients of resources related to improving general health and PMPH Community Wellness program offerings and facilitate enrollment as appropriate.

• Must be comfortable with having discussions with advance care documents and end of life decision making.

• The role will require going to community skilled nursing facilities and rounding on patients in-house or in patient's home for home care.

Credentials:

• LCSW or LSW (Required)

Education or Equivalent Experience:

• Master's degree required.

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.

Live Your Life's Work

We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.

REQNUMBER: UPHS-INFOR-213481