RN Nurse Navigator - Positive Health Clinic - Pittsburgh

Highmark Health•Pittsburgh, PA

About The Position

The RN Nurse Navigator serves as a consistent point of contact for referring physicians, patients, caregivers, families, and the community. The role facilitates patient flow by coordinating appointments and helping patients access clinical and supportive care services within the Network. In collaboration with a multidisciplinary team, the Nurse Navigator coordinates all aspects of care for adult patients with a specialized disease state to support quality, comprehensive services. The role also identifies community needs and provides education, screening, support, referrals, care coordination, and other identified assistance. The position includes community outreach and relationship-building with network partners, coordination of screening and treatment-related care, and support for safe handoffs between facilities and care settings. The Nurse Navigator coordinates multidisciplinary appointments, addresses medication adherence issues, tracks program data and outcomes, identifies care gaps, and participates in clinical care conferences. Travel to other facilities may be required.

Requirements

Current Pennsylvania RN licensure or current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
Bachelor’s degree.
American Heart Association CPR.
Act 34 Criminal Background Clearance Certificate.
Act 33 Child Abuse Clearance Certificate.
Act 73 FBI Fingerprinting Criminal Background Clearance Certificate.

Nice To Haves

Certification in the area of expertise.
Valid Pennsylvania driver’s license.
Knowledge of the healthcare delivery system, resources, and community for the disease-site specialty, and patient advocacy skills.

Responsibilities

Oversee community outreach, high-risk populations, and disease-specific sites to establish and sustain working relationships within the network, including health plans, physicians, office staff, social services staff, and financial counselors.
Work with AHN physician offices and facilities to identify at-risk patients and facilitate appropriate screening.
Travel to other facilities as required.
Educate patients and coordinate care related to diagnosis, treatment options, course of treatment, clinical trial information, and available resources.
Work with the health care team to ensure safe handoffs and coordination of care between facilities and between inpatient and outpatient settings.
Identify bereavement needs of families and develop a plan of care, as applicable.
Work with the Stroke Team to reduce readmissions.
Work with or assist Registry staff with data collection, patient outcomes, and updates to care delivery models, as applicable.
Coordinate appointments involving the multidisciplinary team and accompany patients to appointments as needed.
Ensure medication adherence issues are addressed.
Track data and outcomes established for the navigation program.
Identify gaps and opportunities to improve patient care across the continuum.
Develop or attend clinical care conferences to report on active patients to the multidisciplinary team.