RN Navigator/ACO Specialist

Position Summary:

The RN Navigator/ACO Specialist provides patient-centered clinical navigation, care coordination, and case management services to support patients in accessing appropriate care, improving health outcomes, and effectively managing chronic and complex health conditions. The RN serves as a liaison among patients, caregivers, primary and specialty care providers, health plans, community organizations, and other members of the healthcare team to promote continuity, timely access to services, and effective transitions of care.

The RN Navigator/ACO Specialist provides nursing services within the scope of the Connecticut registered nurse license and applicable state and federal requirements. Responsibilities include patient education and advocacy, care planning and monitoring, coordination of referrals and transitions of care, identification and closure of gaps in care, and connection to appropriate healthcare and community resources. The RN partners with patients and caregivers to support completion of recommended preventive services, including cancer screenings, specialty appointments, and management of medical conditions.

The position supports population health and Accountable Care Organization (ACO) initiatives by using clinical and utilization data to identify opportunities for improved outcomes, access, and cost-effective care. The RN also contributes to regulatory readiness and quality improvement efforts and works collaboratively with physicians, APRN(s), LPNs, Medical assistants, and other members of the interdisciplinary team.

Scope of Nursing Practice: The RN practices in accordance with CT State Statute Sec. 20-87a and within the legal and ethical scope of registered nursing practice. This includes assessing and addressing human responses to actual or potential health problems; providing supportive and restorative care, health counseling and teaching; case finding and referral; collaborating in the implementation of the patient's overall healthcare regimen; and executing authorized medical orders within the applicable scope of practice.

Essential Functions & Responsibilities:

The RN Navigator/ACO Specialist collaborates with the patient care team to coordinate and manage care for identified patient populations, including Medicare and Managed Medicare patients. The position focuses on increasing access to

care, improving health outcomes, supporting quality and value-based care initiatives, and reducing avoidable healthcare utilization and costs.

Core responsibilities include:

• Serve as a primary point of contact, patient advocate, and clinical resource for patients, caregivers, members of the care team, health plans/payors, and community partners.

• Establish and maintain collaborative, team-oriented relationships with physicians, nurses, and other healthcare professionals to support coordinated, patient-centered care.

• Assess patient needs, develop individualized care plans, and monitor progress toward identified clinical, preventive, and care-management goals.

• Coordinate continuity of care and transitions across healthcare settings, including hospital admissions and discharges, primary care, specialty care, referrals, and other external healthcare organizations and facilities.

• Educate and support patients and caregivers so they can make informed decisions regarding their health, clinical status, treatment options, and recommended services.

• Facilitate access to appropriate healthcare, social, and community resources, including resources addressing social determinants of health (SDOH).

• Identify patients appropriate for care management using multiple sources, including provider referrals, transitions-of-care referrals, health plans, and ACO patient lists.

• Provide disease management and complex care management services through in-person, telephone, and technology-enabled interventions, as appropriate.

• Document timely and accurately in the electronic health record and applicable external platforms; review clinical, utilization, and SDOH data to identify and close gaps in care and support appropriate reimbursement.

• Generate, review, and analyze reports and care-management metrics; identify trends and collaborate with providers and the interdisciplinary team to develop and implement strategies to improve outcomes.

• Monitor care-management and utilization measures, including emergency department utilization and hospital admission/readmission activity, and use findings to identify opportunities for intervention.

• Collaborate with primary care providers and specialists to promote clinically appropriate, quality-focused, and cost-effective interventions and outcomes.

• Participate in regular and as-needed meetings with health plan/payor representatives regarding enrolled patients and care-management activities.

• Remain current in care-management practices, quality improvement methodologies, healthcare resources, community services, and relevant ACO and population-health initiatives.

• Provide feedback and recommendations to support the ongoing evaluation and improvement of the Care Coordination Program.

• Develop or support processes for collecting and analyzing data to identify trends in healthcare utilization and opportunities to improve care delivery.

• Contribute to regulatory readiness and quality improvement activities within the scope of the position.

• Participate in interdisciplinary team meetings and other care coordination activities as required.

• Maintain accountability for professional nursing practice and for patient care activities appropriately delegated to others.

• Practice in accordance with applicable ethical, legal, regulatory, organizational, and professional nursing standards.

Additional General Requirements: Professional positive attitude, understanding of customer service principles, trustworthiness, and excellent interpersonal skills.

Education:

• Graduate of an accredited Nursing Program, 4-year Baccalaureate Degree in nursing preferred.
• Experience with electronic platforms and portals to monitor care gaps and close as appropriate.,
• Knowledge of funding resources and clinical standards and outcomes.
• Possess and demonstrate critical thinking skills and clinical problem- solving techniques.
• Knowledge of managed care and population-based disease management concepts and strategies.
• Must have organizational skills.
• Must understand health care systems.
• Applicants must demonstrate the potential ability to perform the essential functions of the job as outlined in the position description.
• Ability to work independently.
• Genuine compassion and respect for all people

Experience: Prior RN Case Management, Discharge Planning, or Care Coordination preferred

Standard Requirements:

• Supports an ethical standard, which complies with a code of conduct free of conflicts of interest.
• Supports the Mission and Values of Community Health & Wellness Center.
• Supports, cooperates with, and/or implements specific procedures and programs for:
  • Safety, including universal precautions and safe work practices, established fire/safety/disaster plans, risk management, and security, report and/or correct unsafe working conditions, equipment repair and maintenance needs.
  • Confidentiality of all data, including patient, employee, and operations data.
  • Quality Assurance and compliance with all regulatory requirements.
  • Compliance with current law and policy to provide a work environment free from harassment and all illegal and discriminatory behavior.
• Cooperates and works together with all co-workers.
• Plans and completes job duties with minimal supervisory direction, including appropriate judgment.
• Use tactful, appropriate communications in sensitive and emotional situations.
• Follow up as appropriate with supervisor and co-workers regarding reported complaints, problems and concerns.
• Promotes positive public relations with co-workers, patients, family members and guests.

Salary Range for the position: starts at $80,000 and salary depends on experience.

Robust benefits package include, but not limited to: Medical, Dental and Vision Insurances, HSA, Life Insurances, 403-b with matching contribution, Provider loan reimbursement.