Post-Acute Navigator

Responsibilities:

• Care Management o Provides concurrent review of patients discharged from Penn Medicine hospitals to post-acute facilities from admission through post-acute facility discharge. o Ensures adequate hand-off to representatives of the next level of care at the point of post-acute facility discharge, including Home Health, Hospice, Primary Care, or other community-based providers of service. o Serves as Penn Medicine’s point of contact for post-acute facility’s interdisciplinary team members up to the interdisciplinary team’s initiation of a Penn Medicine at Home service referral. o Provides support to Penn Medicine’s hospital teams during re-hospitalizations of assigned post-acute facility patients. o Responsible for identifying and implementing facility-specific educational and continuity of care enhancement activities. o Provides direct assistance to post-acute care teams in escalating clinical care concerns to appropriate providers within the Penn Medicine medical staff as defined by each Penn entity. o Monitors appropriate use of post-acute care resources and communicates with external interdisciplinary care teams and medical staff caring for assigned patients throughout the post-hospital care continuum. o Monitors patients through electronic medical record access, telephone, and on-site visits. o Monitors expected post-acute care length of stay and discharge progress for assigned patients. o Identifies patients at high risk for poor outcome and hospital re-admission and provide necessary related support to post-acute providers. o Attends recurring assigned post-acute provider interdisciplinary care and/or utilization team meetings and assists providers in accessing concurrent services to ensure optimal care following hospitalization. o Develops and maintains positive working relationships with external and internal constituents. o Maintains updated knowledge of network capabilities in relation to reimbursement and regulatory considerations impacting post-acute services. o Ensures that post-acute providers are alerted of BPCI status and required follow-up procedures. o Verifies that patients are followed after post-acute facility discharge by appropriate care services, including a PCP appointment and homecare (if appropriate). o Accountable to local entity medical leadership for the implementation of entity-specific protocols. o Participates in local entity network, case management, and related committees as assigned. o Advocates for patient’s rights to autonomy and an informed decision-making process. o Actively engages and participates in community outreach, education, and supportive services. o Advocates for proactive advance care plan discussions and monitor status throughout post-acute services. Quality Improvement o Monitors quality of services delivered by post-acute providers, including length of stay, adequacy of care planning, re-admission, ED visits, and timely discharge planning. o Collects quality and outcomes data and submits quality and utilization reports as assigned. o Prepares activity reports related to assigned patients and providers as requested. o Reviews hospital re-admissions from assigned providers and patients for quality review and care management purposes. o Identifies opportunities for collaboration in the areas of network provider education and continuity and implements provider network initiatives as assigned. o Attends post-acute provider network meetings as required. o Works directly with external providers to ensure that 3rd party documentation requirements are satisfied. o Communicates and participates in Penn Medicine service line/clinical effectiveness teams at the corporate and local entity level. o Participates in health and functional outcomes data collection, clinical audits, and programmatic evaluation related to post-acute initiatives.

Credentials:

• Driver's License (Required)
• Certified Case Manager (preferred) 
• Project Management Professional Certification (preferred) 
• RN or OT or PT or CST (Required)
• PA Licensure required – RN, OT, PT, ST (not required for SW)

Education or Equivalent Experience:

• Bachelor's in nursing, Physical Therapy, Occupational Therapy, Social Work or Speech Therapy (Required) and 2+ years Clinical experience Education Specialization: Nursing, PT, OT, ST, Healthcare Management or Related Field. Will also accept Master’s in Social Work. (Required) 
• Masters Degree (preferred) and 2+ years Clinical experience Education Specialization: Nursing, PT, OT, ST, Healthcare Management or Related Field.
• 2+ years Case Management Experience (preferred) 
• 1+ years Post Acute Care Experience (preferred)