Nurse Navigator, DSNP

The D‑SNP Nurse Navigator is responsible for navigation and advocacy of members who are dually eligible for both Medicare and Medicaid. These members often have complex medical, behavioral health, socioeconomic, and functional needs that require comprehensive care coordination services. The role provides education, supports communication with providers, facilitates referrals, develops individualized care plans, and ensures smooth discharge planning to achieve quality and continuity of care within the managed care system.

Hours:

8:00 am – 5:00 pm.

• Registered Nurse with at least five (5) years’ experience. Three (3) of those years may be work experience as a nurse’s aide, LPN or other appropriate position in a clinical setting. (RN outside minimum experience may be waived for internal applicants currently employed as an LPN with written recommendation of current supervisor or manager).
• Active Ohio or WV licensure upon hire. Ohio or West Virginia multistate licensure must be obtained within the 90-day probationary period and maintained throughout employment, including compliance with State Boards of Nursing and continuing education policy. Other licensure as company expansion warrants.
• Demonstration of excellent oral, written, telephonic and interpersonal skills.
• Proficient keyboarding skills and computer literacy with the ability to navigate through multiple systems.
• Flexibility and the ability to balance an independent and team working environment, multitask, work in a fast‑paced environment, and adapt to changing processes.
• Possession of a superior work ethic and a commitment to excellence and accountability.
• Proven ability to exercise independent and sound judgment in decision making, utilizing all relevant information with proactive identification and resolution of issues.

• Experience in Utilization Management, Quality Improvement, Case Management, Disease Management, or other Managed Care functions.
• Certification in a clinical area related to current work (e.g., CDE, CCM, CMCN, Motivational Interviewing/MI Trainer).

• Coordinate and provide case management services that are safe, timely, effective, efficient, equitable, and client‑centered.
• Handle case assignments, 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.
• Facilitate multiple care aspects (care coordination, condition education, utilization management, information sharing, redirection/transitional care, cost containment, benefit maximization, etc.) across the care continuum, including communication with all relevant multidisciplinary care team members.
• Act as a resource and advocate, helping members make informed decisions about their clinical status and treatment options.
• Develop effective working relations with 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.
• Document interactions with patients and families to track progress toward goals and ensure satisfaction.
• Record case information and complete referrals, reviews, assessments, care plans, notes, activities, forms and workflows accurately and timely to meet case management 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 and protocols, rules and regulations.

The Health Plan is an equal‑opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law.

The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.