Chronic Care Nurse Navigator

Austin Regional Clinic: ARC•Pflugerville, TX

20d

About The Position

The Chronic Care Nurse Navigator coordinates health care services for patients with complex health conditions, serving as an educator and advocate. Through shared decision-making and personalized goal setting, the Nurse Navigator develops care plans in conjunction with Primary Care Providers to optimize patients’ health and wellbeing. The role builds trusting relationships with patients and families, encourages engagement with care plans, recommends screenings and follow-up care using evidence-based medical guidelines, and collaborates with clinical and administrative departments to support comprehensive care. All duties are performed in compliance with confidentiality requirements and in support of the organization’s mission and philosophy. The Nurse Navigator reviews risk-stratification reports and conducts clinical outreach, develops and monitors plans of action, supports patients’ understanding of chronic conditions and medications, and helps them follow through on health goals. The role uses ARC’s EPIC Healthy Planet Population Health module to document patient status, care plans, and intervention outcomes. It also coordinates with providers, clinic staff, health plans, case managers, home health and hospice teams, and community resources to support benefits access, accurate medical records, and transitions from inpatient facilities to home.

Requirements

Graduate of an accredited nursing school and at least one year of direct patient care experience in a clinical environment, or a Bachelor of Science in Health Education and at least one year of direct patient care experience.
Licensed Registered Nurse in the State of Texas.
Basic Life Support (BLS) certification.
Ability to handle multiple projects simultaneously and manage competing priorities.
Excellent customer service, interpersonal, problem-solving, verbal communication, and written communication skills.
Ability to work in a team environment, engage others, listen, adapt responses to meet others’ needs, and align actions with team goals.
Excellent computer and keyboarding skills, including familiarity with Windows.
Ability to perform duties professionally, understand, recall, and communicate factual information, and understand, recall, and apply oral or written instructions.
Ability to organize thoughts and ideas into understandable terminology and apply critical thinking skills.
Familiarity with community agencies and appropriate referral processes.

Nice To Haves

BSN degree.
Experience in case management, home health, or administration.
At least one year of experience working at Austin Regional Clinic.
Spanish-speaking ability; bilingual English and Spanish preferred.

Responsibilities

Review risk-stratification reporting to prioritize patients for clinical outreach.
Contact targeted patients, develop plans of action, ensure the physician’s care plan is followed, and monitor plan status.
Attend patient visits with providers as needed.
Develop trusting relationships with patients and their families.
Collaborate with primary care providers and clinic staff.
Support Medicare Wellness provider staff as needed.
Use Healthy Planet, ARC’s Population Health module in EPIC, to document patients’ current health status, care plans, and intervention outcomes.
Educate patients about chronic health conditions and medications.
Motivate and empower patients to follow through on their health goals.
Work with health plan resources to maximize patient benefits.
Ensure each patient’s medical record accurately and completely reflects their health status.
Coordinate with case managers, home health, and hospice teams to support patients’ transitions from inpatient facilities to home.
Suggest community resources that may benefit patients and contribute information to the shared community resources directory.
Perform other duties as assigned.