Clinical Health Navigator, RN

Higginbotham•Fort Worth, TX

About The Position

The Clinical Health Navigator, RN serves as a trusted clinical resource for employees and their families enrolled in self-funded health plans, helping them navigate complex healthcare decisions and access high-quality, appropriate, and cost-effective care. The Clinical Health Navigator builds ongoing, trust-based relationships with members and provides personalized guidance when healthcare becomes difficult to understand or navigate. The Navigator applies clinical knowledge, healthcare-system expertise, and benefits awareness to help members make informed decisions and overcome barriers to care.

Requirements

Active, unrestricted Registered Nurse (RN) license.
Minimum of five years of clinical nursing experience.
Demonstrated experience caring for patients with complex, chronic, catastrophic, or high-acuity conditions.
Strong working knowledge of medical terminology, disease processes, treatment pathways, medications, specialty care, and the practical realities of healthcare delivery.
Strong understanding of how patients and families navigate providers, health systems, pharmacies, insurance, and other components of the healthcare ecosystem.
Exceptional interpersonal and communication skills, with genuine comfort building trust and rapport with people experiencing stressful or high-stakes healthcare situations.
Ability to explain complex clinical concepts in clear, accessible language to both members and non-clinical business audiences.
Strong critical-thinking and clinical-assessment skills, with the ability to recognize when a situation warrants additional expertise or escalation.
Comfort working with medical and pharmacy claims data to identify patterns, prioritize opportunities, and support proactive member outreach.
Demonstrated ability to work independently while collaborating effectively with physicians, consultants, account teams, vendors, and other healthcare stakeholders.
High degree of professionalism, discretion, empathy, and respect for member privacy and confidentiality.
Proficient with Microsoft Office Suite

Nice To Haves

Bilingual (Spanish or other) a plus.
Certification such as Certified Case Manager (CCM) or equivalent.

Responsibilities

Guide members through complex healthcare moments. Build direct, trust-based relationships with employees and their families navigating serious diagnoses, high-cost treatments, complex care journeys, or difficult healthcare decisions. Help members understand their clinical situation, available options, and benefits well enough to make informed and confident decisions.
Connect members to better care. Identify opportunities for members to access higher-value care, including centers of excellence, independent second opinions, alternative sites of care, specialty pharmacy programs, and other clinical or partner solutions. Personally guide members through the process and help remove barriers to accessing appropriate care.
Identify members who need support before situations escalate. Review medical and pharmacy claims data to proactively identify high-cost claimants, emerging complex conditions, significant changes in utilization, and other indicators that a member may benefit from clinical outreach. Develop a thoughtful outreach approach rather than relying solely on referrals.
Translate the clinical story behind the claims. Partner closely with the Medical Director to help account teams and benefits consultants understand the clinical realities underlying claims, utilization, and emerging health plan costs. Provide clinical perspective in client conversations when it can meaningfully inform strategy or decision-making.
Coordinate across the healthcare ecosystem. Serve as a trusted liaison among members, providers, and the organization's network of care-management vendors, specialty pharmacy programs, centers of excellence, and other healthcare partners. Coordinate communication and follow-through to help ensure that members receive the support and resources they need.
Help employers understand emerging clinical and cost drivers. Partner with consulting teams to translate complex clinical situations, utilization patterns, and emerging healthcare trends into clear, practical insights for HR leaders and executives.
Partner with the Medical Director on complex cases. Collaborate with the Medical Director when a case requires physician-level clinical judgment, escalation, or additional clinical expertise. Maintain clear professional boundaries and ensure that all member guidance remains within the RN's scope of practice.
Document and communicate effectively. Maintain timely, accurate documentation of member interactions, recommendations, outreach, and follow-up activities while protecting member privacy and confidentiality.