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Post-Acute Navigator

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Job ID: 200703
Category: Nursing
Work Type: FT
Location: Bala Cynwyd, PA, United States
Work Schedule: Full Time Day shift

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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?


  • Provides coordination of care for Penn Medicine patients in the Penn Post-Acute Care Networks to ensure the right level of care is provided and to help prevent re-hospitalizations. This includes monitoring the appropriate use of post-acute provider services, connecting post-acute providers to hospital resources for escalation of care, and directing post-acute providers in accessing Penn Medicine services for patients following hospital discharge.


  • 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.


  • 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)

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.

   Current UPHS employees must apply HERE
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