RN Nurse Navigator- Clinically Integrated Network, Hybrid

Company : Allegheny Health Network Job Description : 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 Erie area travel to CIN primary care practices is required along with travel to Warren, PA area GENERAL OVERVIEW: Serves as the consistent point 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 within the Network. The RN Nurse Navigator coordinates all aspects of care in collaboration with the multidisciplinary team for all adult patients within 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. ESSENTIAL RESPONSIBILITIES: Oversees community outreach, high risk populations and disease specific sites to establish and sustain working relationships within 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 handoff, 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 all 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 develop plan of care. Performs other duties as assigned or required. QUALIFICATIONS: Minimum Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) 1-3 year(s) nursing experience in the specialty required. CPR – American Heart Association Act 34 Criminal Background Clearance Certificate Act 33 Child Abuse Clearance Certificate Act 73 FBI Fingerprinting Criminal Background Clearance Certificate Preferred Bachelor's Degree in Nursing Certification in area of expertise. Valid PA driver's license may be required. Older Adults Protective Services Act (OAPSA) clearance may be required depending on location. Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job 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 all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply 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. 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Based in Pittsburgh, Pa., Highmark Health’s 35,000 employees serve millions of customers nationwide through the nonprofit organization’s affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services. Highmark Health’s businesses proudly serve a broad spectrum of health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.