Senior RN Clinical Care Navigation & Vendor Liaison Coordinator

About Texicare

Texicare was founded in 2023 as a mission-driven health affiliate of Texas Mutual, headquartered in Austin, Texas. It aims to improve healthcare access for small businesses and their families through innovative solutions.

Position Summary

Reporting to the Chief Clinical Officer, you will serve as the health plan's clinical point of contact for complex care coordination, care navigation, utilization management, and case management escalations. You will act as a key liaison between the health plan, vendor clinical teams, and internal stakeholders to resolve member care concerns and support a seamless healthcare experience.

Essential Job Functions

• Assume responsibility for clinical escalation management, serving as a clinical resource and subject matter expert on managed care processes, care coordination workflows, utilization management practices, and member navigation challenges.

• Act as the health plan's clinical point of contact for complex care coordination, care navigation, and member care escalations. Assess escalated cases to determine clinical context, urgency, barriers to care, and appropriate next steps.

• Manage urgent, complex or high-profile member issues involving utilization management, care management, provider access, transitions of care, benefits, and healthcare navigation.

• Partner with outsourced utilization management and case management vendors to facilitate timely resolution of escalated member concerns and ensure appropriate care coordination activities occur.

• Monitor vendor responsiveness, follow-through, and resolution outcomes, escalating concerns as appropriate to vendor leadership and internal stakeholders.

• Coordinate with internal departments including Customer Experience, Provider Relations, Compliance, Quality, Operations, and Medical Management to support effective issue resolution.

• Identify clinical, quality, access, compliance, privacy, grievance, or member safety concerns and ensure timely escalation to appropriate clinical or operational leaders.

• Recognize high-risk or urgent situations requiring involvement of vendor clinical teams, Medical Directors, Behavioral Health, Compliance, Quality, or executive leadership.

• Maintain accurate documentation of escalations, interventions, communications, and outcomes in accordance with HIPAA, regulatory, and organizational requirements.

• Analyze escalation trends, member barriers, and vendor performance issues, recommending process improvements that enhance care coordination, member experience, and operational effectiveness.

• Recommend improvements to workflows, vendor handoffs, internal scripts, documentation templates, and service-level expectations.

• Draft internal policies and procedures as needed.

Qualifications

• A bachelor’s degree or any equivalent combination of education, training, and experience.

• A current, unrestricted Registered Nurse (RN) license to practice in Texas.

• At least 4 years of experience in managed care utilization management, case management, care coordination, clinical operations, complex care navigation, or any equivalent combination of education, training, and experience.

• Experience working with delegated clinical vendors and managed care partners, including vendor oversight, escalation management, service issue resolution, or clinical operations support.

• A strong understanding of managed care processes, including utilization management, care management, care transitions, provider access, appeals and grievances, and delegated service models.

• The ability to assess clinical situations, identify risks and barriers to care, determine appropriate escalation pathways, and coordinate resolution across multiple stakeholders.

• Experience supporting commercial health plans, employer-sponsored health plans, and/or self-funded employer groups.

• A working knowledge of NCQA, URAC, CMS, HIPAA, state insurance regulations, and healthcare privacy requirements.

• Excellent communication, relationship management, documentation, organization, and problem-solving skills.

• The ability to independently manage multiple priorities while maintaining attention to detail and follow-through in a fast-paced environment.