Nurse Navigator, DSNP

Metadata: Full-time, Monday–Friday, 8:00 AM–5:00 PM.

About the role

The D-SNP (Dual-Eligible Special Needs Plan) Nurse Navigator coordinates and advocates for members who are dually eligible for both Medicare and Medicaid. These members often have complex medical, behavioral health, socioeconomic, and functional needs requiring comprehensive care coordination. The role ensures quality and continuity of care within the managed-care system by providing education, support, and intervention across a wide spectrum of services.

Responsibilities

• Coordinate and provide safe, timely, effective, efficient, equitable, and client-centered case management services.
• Handle case assignments, perform comprehensive assessments (medical, behavioral, functional, and social determinants of health), develop and maintain care plans, review case progress, and determine case closure.
• Help members achieve wellness and autonomy.
• Facilitate care coordination, condition education, utilization management, information sharing, transitional care, cost containment, and benefit maximization across the care continuum.
• Communicate with multidisciplinary care team members to ensure continuity of care.
• Act as a resource and advocate for members, helping them make informed decisions about their clinical status and treatment options.
• Develop effective working relationships within the industry and cooperate with medical/behavioral team members throughout the care coordination process.
• Arrange non-benefit services with community-based agencies, external social services, health, and governmental agencies.
• Thoroughly document interactions with patients and families to track progress toward goals and ensure satisfaction.
• Record case information, complete referrals, reviews, assessments, care plans, notes, activities, forms, and workflows accurately and timely to meet interrater review benchmarks and 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 substituted with work experience as a nurse’s aide, LPN, or other appropriate clinical position (waiver possible for internal LPN applicants with supervisor recommendation).
• 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 environments, multitask, and adapt to changing processes in a fast-paced setting.
• Superior work ethic and commitment to excellence and accountability.
• Proven ability to exercise independent and sound judgment in decision-making, utilizing all relevant information to proactively identify and resolve issues.

Preferred Qualifications

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