Case/Disease Management Nurse Navigator

Registered Nurse position focused on assessing and coordinating care for moderate to high-risk health plan members through individualized care plans.

Responsibilities

• Assess moderate to high-risk patients for case/disease management intervention.
• Coordinate cost-effective, quality-based healthcare services tailored to members’ needs, benefit plans, and community resources.
• Develop, implement, monitor, evaluate, revise, or close treatment plans as appropriate.
• Provide education, support, and oversight to team members managing low-risk members.
• Interface with medical/behavioral service providers to facilitate communication, referrals, discharge planning, and care plan development.
• Initiate contact with patients, families, physicians, and healthcare providers to discuss care plans.
• Evaluate cases for quality of care and communicate case management plans and decisions.
• Adhere to policies and procedures, performing care coordination duties and documentation in a timely manner.
• Handle moderate to high-risk and/or complex cases, leading the multi-disciplinary care planning process.
• Coordinate and provide safe, timely, effective, efficient, equitable, and client-centered case management services.
• Perform comprehensive medical, behavioral, functional, and social determinant of health assessments.
• Develop and maintain care plans, review case progress, and determine case closure.
• Help members achieve wellness and autonomy through care coordination, condition education, utilization management, and transitional care.
• Act as a resource and advocate to help members make informed decisions about their clinical status and treatment options.
• Develop effective working relationships with multidisciplinary care team members.
• Arrange non-benefit services with community-based agencies, external social services, and governmental agencies.
• Document interactions with patients and families to track progress toward goals and ensure satisfaction.
• Complete referrals, reviews, assessments, care plans, notes, and forms accurately and timely to meet regulatory standards (NCQA, CMS, BMS).
• Promote quality and cost-effective interventions and outcomes in accordance with plan benefits.
• Assess and address motivational and psychosocial issues.
• Adhere to professional standards as outlined by protocols, rules, and regulations.

Requirements

• Active Ohio or West Virginia RN licensure upon hire; multistate licensure must be obtained within the 90-day probationary period and maintained throughout employment.
• Minimum of five (5) years’ experience as a Registered Nurse; three (3) of those years may be as a nurse’s aide, LPN, or other clinical role (waivable for internal LPNs with supervisor recommendation).
• Preferred critical care or other acute care experience.
• Excellent oral, written, telephonic, and interpersonal skills.
• Proficient keyboarding skills and computer literacy with the ability to navigate multiple systems.
• Flexibility to balance independent and team work, multitask, and adapt to changing processes in a fast-paced environment.
• Superior work ethic, commitment to excellence, and accountability.
• Ability to exercise independent and sound judgment, proactively identifying and resolving issues.

Qualifications

• Desired experience in Utilization Management, Quality Improvement, Case Management, Disease Management, or Managed Care.
• Certification in a clinical specialty (e.g., CDE, CCM, CMCN, Motivational Interviewing/MI Trainer).

Schedule

8:00 AM – 5:00 PM, 40 hours per week.