Community Health Navigator
Company: Penn Medicine
Location: Plainsboro
Posted on: April 24, 2024
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Job Description:
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:
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:
Education or Equivalent Experience:
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
Keywords: Penn Medicine, Levittown , Community Health Navigator, Healthcare , Plainsboro, Pennsylvania
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