Penn Medicine, University of Pennsylvania Health System · 12 hours ago
Care Navigator Neurology
Philadelphia, PA
Full-time
Onsite
Mid Level
3+ years expPenn Medicine is dedicated to providing high-quality care, conducting innovative research, and educating future leaders in medicine. The Care Navigator for the GUIDE program will support dementia patients and their caregivers by coordinating care, updating care plans, and providing education and resources.
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Responsibilities
Act as the primary point of contact for patients and their caregivers to provide on-going support, education and resource planning
Provide ongoing education about patient’s condition, its progression, managing related behaviors, maintaining safety in the home, and other caregiving tasks
Provide resources to help caregivers maintain their wellbeing and manage stress
Offer emotional support, active listening, and caregiver skill building
Under clinical supervision, ask screening questions and document patient safety, behavior, function, medications, care needs, and advanced care plans
Under clinical supervision, ask screening questions and document caregiver issues such as burden, depression, and poor coping
Screen for unmet care needs, including clinical or medication issues, behavioral issues, safety risks, advanced care planning needs, and psychosocial well-being
Provide connections to local community services and resources
Assist with medication adherence and medication management strategies, including monitoring side effects and changes in function or behavior
Monitor delivery of care through documentation and tracking of interventions in the electronic health record (such as specialist appointments, outreach calls, post-hospitalization follow-up, respite services, and home safety evaluations)
Ensure equitable access to services and resources, provide culturally appropriate support, and assist with addressing barriers such as language, literacy, technology, or financial challenges
Assist with developing written personalized care plans that incorporate the patient’s goals, strengths, preferences, needs and also modifying care plans to reflect changes as needed
Ensure care plans are incorporated into the patient’s electronic health record and shared with their primary care provider and other relevant healthcare providers
Maintain regular contact with patients and their caregivers, adjusting the frequency of contact based on the patient’s complexity and needs
Gauge completion of specific interventions outlined in the Care Plan such as completion of appointments, medication adherence, use of community resources, and other recommended follow-up activities
Use various modalities (phone, video calls, messaging) for ongoing contact
Ensure access to support for patients and caregivers during business hours and refer to after-hours resources for 24/7 coverage
Consult with and escalate complex or medical issues to licensed clinical team members, such as clinicians, nurses, social workers, or pharmacists
Report screening to the clinical team who will provide direction in implementing a care plan with the Care Navigator, patient, caregiver, health care and community service providers
Participate in interdisciplinary team meetings to review care concerns and address any emerging issues
The Care Navigator is expected to participate in initial and ongoing training
The Care Navigator may be assigned additional responsibilities at their manager's discretion
Performs duties in accordance with Penn Medicine and entity values, policies, and procedures
Other duties as assigned to support the unit, department, entity, and health system organization
Qualification
Required
H.S. Diploma/GED AND 3+ years of relevant health care experience in a similar role
OR Associates degree in health-related or science area of study and 1+ years of relevant health care experience in a similar role
OR Bachelors degree in health-related or science area of study
Benefits
Prepaid tuition assistance programs
Company
Penn Medicine, University of Pennsylvania Health System
Penn Medicine is a world leader in academic medicine, setting the standard for cutting-edge research, compassionate patient care, and the education of future health care professionals.
10001+ employees
Funding
Current Stage
Late StageTotal Funding
$70.9MKey Investors
BIRD FoundationWarren Alpert FoundationNational Cancer Institute
2025-01-22Grant
2023-01-03Grant· $9.7M
2022-08-18Grant· $5.7M
Leadership Team
Kevin Mahoney
Chief Executive Officer of University of Pennsylvania Health System
John Donohue
Vice President, Enterprise Services
Recent News
The Philadelphia Inquirer
2026-01-03
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