Care Navigator Neurology

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? Job Title: Care Navigator Neurology Department: Neurology Cognitive Guiding an Improved Dementia Experience (GUIDE) Location: Perelman Center for Advanced Medicine - 3400 Civic Center Blvd Hours: Mon-Fri office hours Summary: + The Care Navigator for Penn Medicineu2019s Guiding an Improved Dementia Experience (GUIDE) program will work within the Department of Neurology to support patients with dementia, and their caregivers by updating & following care plans, identifying unmet needs, coordinating clinical & community-based services, aiding medication adherence, providing caregiver education, coaching, & support, coordinating care w/ PCPs & specialists, providing transitional care management between home & other settings, and referring & connecting patients/caregivers to services & supports. + The Care Navigator is the primary point of contact for patients and their caregivers enrolled in the program and maintains regular contact with program participants through phone calls and other electronic means. They will collaborate with physicians, nurses, and social workers, as part of a care team, and they will review clinical cases weekly with other care team members. They additionally perform tasks to facilitate patientsu2019 program enrollment and ongoing participation such as collecting data on patient quality of life, caregiver distress, and health-related social needs Responsibilities: + Primary Contact and Support: + 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 patientu2019s 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. + Care Coordination: + 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. + Person-Centered Care Planning: + Assist with developing written personalized care plans that incorporate the patientu2019s goals, strengths, preferences, needs and also modifying care plans to reflect changes as needed. + Ensure care plans are incorporated into the patientu2019s electronic health record and shared with their primary care provider and other relevant healthcare providers. + Ongoing Monitoring and Support: + Maintain regular contact with patients and their caregivers, adjusting the frequency of contact based on the patientu2019s 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. + Collaboration with Clinical Team: + 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 Education or Equivalent Experience: + H.S. Diploma/GED AND 3+ years of relevant health care experience in a similar role (Required) + OR Associates degree in health-related or science area of study and 1+ years of relevant health care experience in a similar role (Required) + OR Bachelors degree in health-related or science area of study (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 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: 304862

Created: 2026-02-04