Patient Navigator- Care Management (Full Time/ Days)

Description

Penn Medicine is dedicated to its tripartite mission of providing the highest quality of care to patients, conducting innovative research, and educating future leaders in medicine. Working here means collaborating with top clinical, technical, and business professionals across all disciplines.

About the role

The Patient Navigator PN will be an integral member of the Care Management multi-disciplinary outreach team. Together with Care Managers, Social Workers, and providers, the PN will assist in care plan development and implementation, provide advocacy to patients, help develop care management strategy for enrolled patients, and help create linkages for the various health and social needs of patients. The PN will be the direct contact for patients enrolled in the program and will help provide the coaching necessary for identified patients to achieve success in implementing and achieving their healthcare goals. The PN will lead the multi-disciplinary team meetings huddles and implement suggested approaches to providing better care. The PN will meet the patients in all settings including home, inpatient, outpatient, and specialty office settings, as appropriate.

Responsibilities

• Determines plans for care management
• Carefully coordinates care plans and completes tasks as necessary to complete social behavioral care plan goals
• Coordinates public assistance entitlements
• Coordinates behavioral health services
• Triage after hours questions from enrolled patients as appropriate
• Accompanying patients to appointments as needed
• Arranging referrals to any additional services such as supportive housing programs, legal aid, etc.
• Aids patients in learning medication adherence systems, as well as conducting medication reconciliations as appropriate
• Acts as a liaison between the Emergency Department, specialists, community resources, and managed care insurance plans on behalf of enrolled patients to ensure patient-centered coordination of care
• Engages in the coaching of patients and caregivers on health literacy as determined necessary in achieving identified goals
• Forges and nurtures partnerships with local service organizations and community resources to broaden support services for patients
• Enters and maintains electronic records, compiles reports, and completes other program documentation and administrative responsibilities in a timely manner such as progress notes, incident reports, client track, letters, etc.
• Participates in interdisciplinary case conferences team meetings huddles
• Consistently and actively plays a role in identifying project inefficiencies and finding collaborative solutions to the problems

Qualifications

• High School Diploma or General Equivalency Degree GED with at least one year of experience in the social services and/or medical field or as a former high-risk patient who successfully transformed their health, in conjunction with healthcare providers, utilizing education and controlled preventative measures
• Strong understanding of medical terminology, case management, and/or outreach services
• Exceptional organizational and interpersonal skills, with attention to detail required; strong oral and written communication skills is a must
• Demonstrated ability to work collaboratively in a team, manage multiple priorities, utilize effective time management skills, and exercise sound administrative and clinical judgment
• Demonstrated comprehensive knowledge of social and community resources
• Prior acute hospital experience or ambulatory practice experience
• Prior experience with patient home visits

Preferred Qualifications

• Licensed Practical Nurse LPN, Paramedic Emergency Medical Technician, or other licensed health care practitioner
• Bilingual (proficiency in the Spanish language)