Population Health Nurse Navigator

About the role

The Population Health Nurse Navigator functions as a member of the multidisciplinary team to provide patient-centered care coordination, education, advocacy, and navigation for patients enrolled in value-based care, CICIP-funded programs and other home-based and post-acute care models. The role focuses on improving outcomes by coordinating safe and effective transitions across the healthcare continuum and supporting patients in accessing appropriate medical, behavioral health, community, and home-based services. The Nurse Navigator serves as an advocate, navigator, collaborator, educator, and care management expert by identifying and addressing barriers to care, promoting self-management and prevention, coordinating services, supporting medication adherence, and connecting patients and caregivers with appropriate resources. The role partners with patients, families, providers, and multidisciplinary teams to ensure patients receive the support, resources, and coordination needed to navigate the healthcare system and achieve their health goals.

Responsibilities

• Managing complex and high-risk patient populations
• Facilitating timely follow-up and primary care connections
• Supporting chronic and behavioral health needs
• Coordinating transitions of care
• Connecting patients with community resources to address social and non-medical needs
• Working to divert preventable inpatient and Emergency Department utilization to appropriate outpatient, community, and home-based settings
• Improving patient outcomes and experience, reducing avoidable healthcare utilization and costs, and increasing delivery of recommended preventive services

Minimum Education Required

Bachelor's Level Degree in Nursing from a CCNE (Commission on Collegiate Nursing Education) or Accreditation Commission for Education in Nursing (ACEN) accredited nursing program required.

Requirements

• A Bachelor of Science in Nursing (BSN) required
• Current Ohio RN licensure
• A minimum of three years of recent clinical experience is preferred
• Five years and experience in primary care, case management, or post-acute settings (home health, SNF, or LTACH) highly desirable
• Knowledge of evidence-based practice, disease-specific processes, healthcare technology, payer protocols, and the healthcare continuum
• Strong clinical judgment, problem-solving, communication, interpersonal, and collaboration skills
• Ability to work independently and navigate complex patient needs
• Supervisory or preceptor experience is highly desired