Population Health Nurse Navigator

The Ohio State University

8d•Onsite

About The Position

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. Key responsibilities include 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, and connecting patients with community resources to address social and non-medical needs. The Nurse Navigator works to divert preventable inpatient and Emergency Department utilization to appropriate outpatient, community, and home-based settings, with the goals of improving patient outcomes and experience, reducing avoidable healthcare utilization and costs, and increasing delivery of recommended preventive services. Candidates should have knowledge of evidence-based practice, disease-specific processes, healthcare technology, payer protocols, and the healthcare continuum. The role requires strong clinical judgment, problem-solving, communication, interpersonal, and collaboration skills, with the ability to work independently and navigate complex patient needs.

Requirements

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.
Current Ohio RN licensure.
A minimum of two years of recent clinical experience is required.
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.

Nice To Haves

Five years of experience in primary care, case management, or post-acute settings (home health, SNF, or LTACH) highly desirable.
Supervisory or preceptor experience is highly desired.

Responsibilities

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.
Improve outcomes by coordinating safe and effective transitions across the healthcare continuum.
Support patients in accessing appropriate medical, behavioral health, community, and home-based services.
Identify and address barriers to care.
Promote self-management and prevention.
Coordinate services.
Support medication adherence.
Connect patients and caregivers with appropriate resources.
Partner 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.
Manage complex and high-risk patient populations.
Facilitate timely follow-up and primary care connections.
Support chronic and behavioral health needs.
Coordinate transitions of care.
Connect patients with community resources to address social and non-medical needs.
Divert preventable inpatient and Emergency Department utilization to appropriate outpatient, community, and home-based settings.
Improve patient outcomes and experience.
Reduce avoidable healthcare utilization and costs.
Increase delivery of recommended preventive services.