Post-Acute Navigator - Full time- Penn Medicine at Home

Description

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?

Summary:

Supports the Penn Medicine Sub Acute Therapy Services (SATS) Division's key imperatives: High-performing Networks/Partners, "Right Care' Transitions, and Innovative Models of Care. Provides coordination of care for Penn Medicine patients in Penn Post-Acute Care Networks to ensure right level of care is provided, a reduction in readmissions, emergency department utilization, and average length of stay in skilled rehab. Supports initiatives directed toward engagement in quality programming offerings that promote resiliency in long term care communities. Finally, but foundationally, is accountable to facilitate a highly effective work culture for SATS and its reputation within Penn Medicine a well as among external stakeholders.

Responsibilities:

Navigation:

Serves as Penn Medicine’s point of contact for Post-Acute facility’s interdisciplinary team members.

Serves as a liaison for bi-directional communication/information sharing as patients navigate transitions of care.

As assigned, manages a caseload of patients discharged from Penn Medicine hospitals to Post-Acute Network facilities from admission through Post-Acute facility discharge in support of SATS imperatives.

Monitors patients through electronic medical record access, telephone, and on-site visits Advocates for proactive advance care plan discussions and monitor status throughout Post-Acute services.

Advocates for patient’s rights to autonomy and an informed decision-making process.

Identifies patients at high risk for poor outcome and hospital re-admission and provide necessary related support to Post-Acute providers.

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.

Develops and maintains positive working relationships with external and internal constituents.

Monitors Network facility quality outcomes, developing action plans and education to address deficiencies, in collaboration with SATS Regional Leadership.

Maintains updated knowledge of network capabilities in relation to reimbursement and regulatory considerations impacting Post-Acute services.

Communicates and participates in Penn Medicine service line/clinical effectiveness teams at the corporate and local entity level.

Quality Programming:

Accountable for development and/or implementation of plans for facility quality initiatives - supporting the ongoing coordination and evaluation of the plan initiated through the RISE grant in collaboration with PI Advisor and Sub-Contractors serving all types of long term care facilities. Functions as the subject matter expert as well as primary resource for clinical quality expertise for the Long-Term Care (LTC) Resiliency Grant initiative.

Participates in health and functional outcomes data collection, clinical audits, and programmatic evaluation related to Post-Acute initiatives.

Credentials:

Driver's License (Required)

RN, OT, PT, ST, LSW or LCSW (Required)

PA Licensure required – RN, OT, PT, ST, LSW or LCSW

Education or Equivalent Experience:

Bachelor of Arts or Science and 2+ years Clinical experience (required)

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.

REQNUMBER: 222923