Population Health Nurse Navigator
Core
Provide patient-centered care coordination, education, advocacy, and navigation for patients enrolled in value-based care and post-acute models to improve outcomes and reduce avoidable healthcare utilization.
Role type
Senior IC Population Health Nurse Navigator
Builds
Safe and effective transitions across the healthcare continuum for complex, high-risk patient populations
Domain
Healthcare / Population Health Management
Required skills
Clinical judgment, care coordination, chronic disease management, behavioral health support, transition of care management, community resource navigation, medication adherence support, evidence-based practice knowledge
Preferred skills
Primary care experience, case management, post-acute settings (home health, SNF, LTACH), supervisory or preceptor experience
Technologies
Healthcare technology, payer protocols
Responsibilities
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 settings