Nurse Navigator Medical Cost Management
About the position Responsibilities • Serve as a clinical resource and point of contact for high-risk and high-cost members, guiding them through care coordination and benefit utilization. • Educate members on chronic disease management, preventive care, and appropriate use of healthcare services, with a focus on diabetes and ESRD. • Identify and address social determinants of health (SDOH) that impact access to care and adherence to treatment plans. • Support members in locating in-network providers and facilities to reduce out-of-network and emergency room usage. • Coordinate referrals, post-discharge planning, and medication adherence strategies. • Collaborate with network case managers, social workers, and providers to ensure timely and appropriate care delivery. • Conduct outreach to at-risk populations to promote engagement in wellness programs and adherence to care plans. • Partner with community-based organizations to connect members with additional support services. • Document all member interactions and interventions in compliance with HIPAA and payer-specific guidelines. • Monitor and report trends related to gaps in care, member concerns, and program effectiveness. Requirements • 3+ years of experience in care coordination, case management, or patient navigation. • Strong understanding of health insurance plans, provider networks, and value-based care models. • Clinical experience in chronic disease management, especially diabetes and ESRD. • Excellent communication, critical thinking, and interpersonal skills. • Ability to work with diverse populations and address health equity challenges. • Proficiency in electronic health records (EHR) and payer systems. • Knowledge of community health resources and support services. • Registered Nurse (RN) license required • Certified Diabetes Educator (CDE) or equivalent experience in diabetes education. • Certification in Case Management (CCM), Public Health (CPH), or similar credential. Nice-to-haves • Spanish Bi-lingual skills (preferred). • Experience in managed care or payer settings is a plus. • BSN or higher preferred. Benefits • Medical • Dental • Vision • Paid Time-Off (PTO) • Paid Holidays • 401(k) • Short- & Long-term Disability • Pension • Life • AD&D • Flexible Spending Accounts (healthcare & dependent care) • Commuter Transit • Tuition Assistance • Employee Assistance Program (EAP)