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Community Health Navigator

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Job ID: 201308
Category: Clinical Support
Work Type: FT
Location: Plainsboro, NJ, United States
Work Schedule: FT

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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?


  • 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.


    1. Manage a caseload of patients to provide interventions necessary to maintain optimum health and reduce the emergency room usage.

    1. 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.
    1. Ensure access to follow-up health care by facilitating medical appointments.
    1. Identify needs for advanced care planning and facilitate conversations and completion of documents specific to goals of care (Example: POLST, HCP).
    1. Document all patient interactions and follow-up interventions in EPIC.
    1. Help clients in utilizing resources, including scheduling appointments, and assisting with completion of applications for programs for which they may be eligible.
    1. Assist clients in accessing health related services, including but not limited to overcoming barriers to obtaining needed medical care and social services.
    1. Facilitate patient engagement in routine preventive screenings through PCP, community programs or Clinic.

    1. Advise patients of resources related to improving general health and PMPH Community Wellness program offerings and facilitate enrollment as appropriate.
    2. 10. Attend community meetings or health fairs to understand community issues or build relationships with community members.
    3. Participates in hospital committees as applicable to role and responsibilities
    4. Other duties as assigned.


      • State of New Jersey Licensed Social Worker (LSW) required.
      • National Case Management Certification preferred 
      • Valid Driver's License and automobile insurance required

      Education or Equivalent Experience:

      • Master's degree required. 

      Related Work Experience:

      • At least 2 years related work 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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