Company : Allegheny Health Network Job 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. 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. 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.). Works with AHN physician offices/facilities to identify at-risk patients and assists in facilitating appropriate screening process. Travel to other facilities as required. 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. 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. 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. 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. QUALIFICATIONS: Minimum Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) Bachelor’s degree Preferred 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 Additional Employment Requirements: CPR – American Heart Association Act 34 Criminal Background Clearance Certificate Act 33 Child Abuse Clearance Certificate Act 73 FBI Fingerprinting Criminal Background Clearance Certificate 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. Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. California Consumer Privacy Act Employees, Contractors, and Applicants Notice Highmark Health is a national, blended health organization that includes one of America’s largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network. 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.

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