RN Clinical Care Navigator-Full-Time

Mille Lacs Health System•Onamia, MN

47d

About The Position

The RN - Clinical Care Navigator provides patient-centered nursing care focused on supporting individuals through transitions of care and chronic disease management. The position ensures continuity, safety, and quality outcomes through proactive outreach, coordination, and communication across the healthcare continuum. Summary The RN - Clinical Care Navigator serves as a vital member of the outpatient care team, supporting patients through transitions of care and chronic disease management to improve health outcomes and reduce avoidable hospitalizations. This role focuses on proactive, relationship-based coordination that promotes patient engagement, continuity, and population health across the care continuum. The Clinical Care Navigator partners closely with providers, nurses, social services, and community resources to ensure that patients receive timely, comprehensive, and coordinated care consistent with the organization's value-based and patient-centered goals.

Requirements

Current, unencumbered Registered Nurse (RN) license in the State of Minnesota.
Minimum of two (2) years of clinical nursing experience in an outpatient, hospital, or home health setting.
Excellent communication, critical thinking, and organizational skills.
Ability to work both independently and collaboratively across teams.

Nice To Haves

Prior experience in care coordination, case management, or chronic care management.
Knowledge of population health principles and value-based care models (ACO, MSSP, or similar).
Familiarity with community resources and social determinants of health.
Case Management or Population Health certification (CCM, ACM-RN, or equivalent).

Responsibilities

Transitions of Care (TOC): Conduct outreach following hospital, emergency department, or skilled nursing facility discharges to ensure a safe transition back to the community.
Review discharge summaries, reconcile medications, and schedule timely follow-up visits with the appropriate provider.
Identify and address gaps in care, barriers to adherence, or unmet social needs.
Document all TOC activities per organizational standards and CMS requirements.
Chronic Care Management (CCM): Identify eligible patients with multiple chronic conditions and enroll them in CCM programs.
Develop individualized care plans that include patient goals, interventions, and self-management education.
Perform monthly check-ins (phone or in-person) to monitor progress, reinforce education, and coordinate services.
Support quality measures related to chronic disease control, medication adherence, and preventive screenings.
Care Coordination & Population Health: Serve as the point of contact for patients and families navigating the healthcare system.
Collaborate with providers and interdisciplinary staff to ensure cohesive, team-based care.
Track and manage patients within registries to close preventive care gaps.
Engage community partners to connect patients with social or behavioral health resources.
Participate in quality-improvement and value-based initiatives to advance patient outcomes.
Team Collaboration: Participate in daily huddles, case conferences, and multidisciplinary care planning meetings.
Provide feedback to enhance workflows and optimize patient flow.
Maintain accurate, timely documentation in the electronic health record (EHR).
Uphold confidentiality, HIPAA compliance, and professional nursing standards.