RN Nurse Navigator - Stroke Program - Jefferson Hills

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 states 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.

Travel is required.

• 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 the health‑care team to ensure safe handoff and coordination of care between facilities, including inpatient to outpatient or outpatient to inpatient transitions. Collaborates with High‑Risk Care Teams to reduce re‑admissions. May assist Registry staff with data collection, patient outcomes, and updates to care delivery models.
• Coordinates appointments, including all aspects of the multi‑disciplinary team (physicians, consultants, supportive care services, etc.) and accompanies patients as needed. 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 on active patients to the multidisciplinary team.
• May identify bereavement needs of families and develop a plan of care.
• Performs other duties as assigned or required.

• Current State of PA RN licensure OR current multi‑state licensure through the enhanced Nurse Licensure Compact (eNLC)
• 1‑3 years nursing experience in the required specialty
• CPR – American Heart Association certification
• Act 34 Criminal Background Clearance Certificate
• Act 33 Child Abuse Clearance Certificate
• Act 73 FBI Fingerprinting Criminal Background Clearance Certificate

• 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

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