RN Nurse Navigator- Clinically Integrated Network, Hybrid

About the position This position offers an exciting opportunity to work closely with AHN and independent primary care practice teams participating in AHN's Clinically Integrated Network (CIN) to enhance the quality and value of care delivered to Medicare beneficiaries. You will collaborate with practices to assist patients with self-management support, disease management, and care coordination to help them meet their health goals. This role supports a new value-based reimbursement model for Medicare beneficiaries focused on improving population health, quality, and patient experience. This is a hybrid role that involves both on-site and remote work. Services will be provided at primary care practices as well as telephonically. Regional Pittsburgh area travel to CIN primary care practices is required. GENERAL OVERVIEW: Serves as the consistent reputed company of contact for referring physicians, patients, caregivers, families, and the community. Facilitates patient flow, including coordination of appointments and assists the patient with accessing clinical and supportive care services reputed company the Network. The RN Nurse Navigator coordinates reputed company aspects of care in collaboration with the multidisciplinary team for reputed company adult patients reputed company specialized disease state to ensure they receive quality and comprehensive services. Identifies community needs and provides education, screening, support, referrals, coordination of care, and any other assistance identified as necessary.

Responsibilities

• Oversees community reputed company, high risk populations and disease specific sites to establish and sustain working relationships reputed company the network (health plan, physicians, office staff, social services staff, financial counselor, dietician, etc.).
• Educates and coordinates care regarding patient's diagnosis, treatment options, course of treatment, clinical trial information and resources available.
• Works with health care team to ensure safe reputed company, coordination of care between facilities as well as inpatient to outpatient or outpatient to inpatient coordination of care.
• Works with High-Risk Care Teams to reduce re-admissions.
• May work with and/or assist Registry staff with data collection, patient outcomes and updates care delivery models.
• Coordinates appointments including reputed company aspects of the multi-disciplinary team (physicians, consults, supportive care services, etc. and accompanies patients as needed to appointments.
• Ensures that medication adherence issues are addressed.
• Works with AHN physician offices/facilities to identify at-risk patients and assists in facilitating appropriate screening processes.
• Trends data and outcomes as established for the navigation program.
• Identifies gaps to improve patient care across the continuum.
• Develops or attends an existing clinical care conference to report out on active patients to the multidisciplinary team.
• May identify bereavement needs of families and reputed company plan of care.
• Performs other duties as assigned or required.

Requirements

• Minimum reputed company State of PA RN licensure OR reputed company multi-state licensure through the enhanced Nurse Licensure Compact (eNLC)
• 1-3 year(s) nursing experience in the specialty required.
• CPR – reputed company
• Act 34 Criminal Background Clearance Certificate
• Act 33 Child Abuse Clearance Certificate
• Act 73 FBI Fingerprinting Criminal Background Clearance Certificate

reputed company-to-haves

• Bachelor's Degree in Nursing
• Prior Case Management experience highly preferred
• Certification in area of expertise.
• Valid PA driver's license may be required.
• Older Adults reputed company Services Act (OAPSA) clearance may be required depending reputed company.

Benefits

• This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
• As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at reputed company times.
• In reputed company with this, reputed company must reputed company with both the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as reputed company data reputed company guidelines established reputed company the Company’s Handbook of Privacy Policies and Practices and Information reputed company Policy.
• Furthermore, it is every employee’s responsibility to reputed company with the company’s Code of Business Conduct.
• This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
• reputed company and its affiliates prohibit discrimination against reputed company individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against reputed company individuals based on any category protected by applicable federal, state, or local law.
• We endeavor to reputed company this site accessible to any and reputed company users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.
• For accommodation requests, please contact HR Services Online at [email protected]
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