Registered Nurse Navigator - Population Health

Role Overview: The RN Navigator in Population Health manages patient care across the healthcare continuum to improve health outcomes through evidence-based practices, preventive care, and timely interventions. Key Responsibilities Coordinate care for patients with chronic or complex conditions and facilitate discharge planning for smooth transitions. Conduct comprehensive patient assessments, develop individualized care plans, and support reducing preventable admissions and ED visits. Educate patients on medication management, recognizing worsening symptoms, and the importance of follow-up care. Advocate for patients within the healthcare system, ensuring access to necessary services. Collaborate with providers, social workers, and community resources for holistic care. Monitor patient status, document interactions in EHR, and participate in quality improvement initiatives. Ensure compliance with regulatory standards and organizational policies. Qualifications & Skills Bachelor’s Degree in Nursing preferred. Minimum of 3 years clinical experience and 2 years case management experience. Knowledge of population health management principles and experience in primary care organizations. RN licensure and certification such as CCM or equivalent within 2 years. Strong clinical assessment, communication, and interpersonal skills, with proficiency in EHR systems. Additional Requirements: Ability to work independently and collaboratively, with a caring approach to patients and colleagues.