Population Health Nurse Navigator
About The Position
The Population Health Nurse Navigator is a member of a multidisciplinary team providing 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 coordinates safe and effective transitions across the healthcare continuum and helps patients access appropriate medical, behavioral health, community, and home-based services. Serving as an advocate, navigator, collaborator, educator, and care management expert, the Nurse Navigator identifies and addresses barriers to care, promotes self-management and prevention, coordinates services, supports medication adherence, and connects patients and caregivers with appropriate resources. The role partners with patients, families, providers, and multidisciplinary teams to help patients navigate the healthcare system and achieve their health goals. The position manages complex and high-risk patient populations, facilitates timely follow-up and primary care connections, supports chronic and behavioral health needs, coordinates transitions of care, and connects patients with community resources for social and non-medical needs. It aims to divert preventable inpatient and Emergency Department utilization to appropriate outpatient, community, and home-based settings, improve patient outcomes and experience, reduce avoidable utilization and costs, and increase delivery of recommended preventive services.
Requirements
- Bachelor's-level degree in Nursing from a CCNE- or ACEN-accredited nursing program.
- Current Ohio RN licensure.
- A minimum of two years of recent clinical experience.
- 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.
- Experience in primary care, case management, or post-acute settings such as home health, SNF, or LTACH.
- Supervisory or preceptor experience.
Responsibilities
- Provide patient-centered care coordination, education, advocacy, and navigation for patients in value-based care, CICIP-funded programs, and home-based and post-acute care models.
- Coordinate safe and effective transitions across the healthcare continuum.
- Identify and address barriers to care; promote self-management and prevention; coordinate services; support medication adherence; and connect patients and caregivers with appropriate resources.
- Collaborate with patients, families, providers, and multidisciplinary teams to support patients in navigating the healthcare system and achieving health goals.
- Manage complex and high-risk patient populations.
- Facilitate timely follow-up and connections to primary care.
- Support patients' chronic and behavioral health needs.
- Connect patients with community resources addressing social and non-medical needs.
- Help divert preventable inpatient and Emergency Department utilization to appropriate outpatient, community, and home-based settings.
- Support improved patient outcomes and experience, reduced avoidable healthcare utilization and costs, and increased delivery of recommended preventive services.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
