Company :Allegheny Health Network
Job Description :
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. 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 a need.
- 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.). Works with AHN physician offices/facilities to identify at-risk patients and assists in facilitating appropriate screening process. Travel to other facilities as required. (10%)
- Educates and coordinates care regarding patient's diagnosis, treatment options, course of treatment, clinical trial information and resources available. (30%)
- 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. May identify bereavement needs of families and develop plan of care. Works with Stroke Team to reduce re-admissions. May work with and/or assist Registry staff with data collection, patient outcomes and updates care delivery models. (30%)
- 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. (10%)
- Trends data and outcomes as established for the navigation program. Identifies gaps to improve patient care across the continuum. (10%)
- Develops or attends an existing clinical care conference to report out on active patients to the multidisciplinary team. (10%)
- Registered Nurse license
- Bachelor’s degree
- Certification in area of expertise
- Valid PA Driver’s license
- Knowledge of the healthcare delivery system, resources, community for the disease site specialty, and patient advocacy skills
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