Nurse Navigator

Description

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

• Registered Nurse required.
• 1-3 year(s) nursing experience in the specialty required.

Preferred

• BSN
• 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.

Summary

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