Job Description
About the position Responsibilities • Oversees community outreach, high risk populations and disease specific sites to establish and sustain working relationships within the network. • 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. • Coordinates appointments including all aspects of the multi-disciplinary team 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. Requirements • Registered Nurse required. • 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. Nice-to-haves • 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. Apply tot his job