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Job ID: 179720
Location: Plainsboro, NJ, United States
DescriptionPenn 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.
Accountable to provide navigation for identified adult patients within the Penn Medicine Princeton Health system. Performs administrative functions to support the coordination of outpatient care needs. Facilitates interventions toward identified community service needs such as food, transportation, advanced care planning, follow- up medical care and other relevant community services to discharged patients for a 90-day period post discharge. 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.
JOB DUTIES AND RESPONSIBILITIES:
1. Manage a caseload of patients to provide interventions necessary to maintain optimum health and reduce the emergency room usage.
2. 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.
3. Ensure access to follow-up health care by facilitating medical appointments.
4. Identify needs for advanced care planning and facilitate conversations and completion of documents specific to goals of care (Example: POLST, HCP).
5. Document all patient interactions and follow-up interventions in EPIC.
6. Help clients in utilizing resources, including scheduling appointments, and assisting with completion of applications for programs for which they may be eligible.
7. Assist clients in accessing health related services, including but not limited to overcoming barriers to obtaining needed medical care and social services.
8. Facilitate patient engagement in routine preventive screenings through PCP, community programs or Clinic.
9. Advise patients of resources related to improving general health and PMPH Community Wellness program offerings and facilitate enrollment as appropriate.
Education • Master's degree required. • Related Work Experience • At least 2 years related work experience preferred. • Can additional experience substitute for education? If “yes”, specify type of experience (i.e. supervisory or nonsupervisory, etc) and identify how many years of additional experience:
LICENSURE, CERTIFICATION OR REGISTRATION REQUIREMENTS:
• State of New Jersey Licensed Social Worker (LSW) required.
• National Case Management Certification preferred.
• Valid Driver’s License and automobile insurance required.
SPECIALIZED SKILLS & KNOWLEDGE REQUIREMENTS:
• Two years of hospital or community social work experience.
• Ability to work independently with minimal supervision.
• Excellent interpersonal and communication skills.
• Bilingual in English and Spanish.
• Strong understanding of cultural competency with the target populations.
• Exposure to issues of death and dying.
• Capacity to understand and negotiate internal and external systems and various stakeholders.
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.