Clinical Navigator

About the Company

Paradigm is an accountable specialty care management organization focused on improving the lives of people with complex injuries and diagnoses. The company has been a pioneer in value-based care since 1991 and has an exceptional track record of generating the very best outcomes for patients, payers, and providers. Deep clinical expertise is the foundation for every part of Paradigm’s business: risk-based clinical solutions, case management, specialty networks, home health, shared decision support, and payment integrity programs.

Paradigm has been certified by Great Place to Work® for the fourth consecutive year and named to Fortune's Best Workplaces in Health Care™ list for the third year in a row, reflecting a commitment to a positive, inclusive, and employee-centric culture.

About the Role

The Clinical Navigator serves as a central coordination and clinical oversight resource for injured workers with complex and catastrophic workers’ compensation claims. In this role, you will partner closely with case managers, clinical associates, providers, payers, vendors, key accounts, and injured workers to remove barriers to care, support timely and medically necessary treatment, and promote positive outcomes.

This is a fully remote position with typical business hours; occasional work outside standard hours may be required based on business needs.

Responsibilities

• Serve as the central point of coordination and clinical oversight for assigned complex and catastrophic cases.
• Act as the secondary level of clinical oversight and single point of contact for Case Managers and Clinical Associates.
• Work directly with key accounts to provide customer excellence in every interaction.
• Apply case management skills to remove barriers, focusing on quality outcomes, compliance, and efficient case progression; evaluate treatment appropriateness and utilization.
• Ensure home health and DME services are performed as ordered and remain clinically necessary; make recommendations based on injured workers’ needs and progress.
• Ensure treatment plans align with medical necessity and payer guidelines; monitor progress and escalate delays or risks.
• Identify delays, risks, and care gaps, escalating appropriately.
• Conduct QA on referrals to ensure alignment with Care at Home guidelines.
• Collaborate with external agencies, providers, and vendors to coordinate care and facilitate communication.
• Facilitate and lead case conferences and virtual roundtable discussions to review patient progress and address barriers.
• Demonstrate a customer-first mindset by understanding Paradigm’s organization, products, operations, and customers; prioritize collaboration to meet customer needs.
• Utilize AI tools to support day-to-day tasks, improve efficiency, and enhance output quality.

Requirements

• Active RN license required.
• 3–5 years of workers’ compensation and/or complex case management experience.
• Experience with catastrophic cases strongly preferred.
• Experience with DME, EMRs, care management platforms, and Microsoft Office applications.
• Knowledge of Utilization Review process.
• Strong communication skills for both internal and external stakeholders.
• Collaborative demeanor with a focus on teamwork.
• Strong conflict resolution, problem-solving, and clinical assessment skills.
• Excellent prioritization, time-management, documentation, and auditing skills.
• Bilingual (English/Spanish) a plus.

Benefits

• Health and wellness: PPO, HDHP, and HMO health insurance options with Cigna and Kaiser (CA employees only).
• Financial incentives: Competitive salaries, 401(k) matching contributions, employer-paid life and disability insurance, flexible spending and commuter accounts, and employer-matched HSA contributions.
• Vacation: Paid time off and personal holiday programs for work-life balance.
• Volunteer time: One paid day per calendar year for community engagement.
• Learning and development: Access to the Learning Excellence at Paradigm (LEAP) program and other growth opportunities.