RN Clinical Care Navigator-Full-Time presso Mille Lacs Health System

Purpose

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.

Essential 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.

Qualifications

Required:

• 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.

Preferred:

• 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).

Equivalent combinations of education, training, and directly related experience will be considered in place of stated qualifications when appropriate.

Work Environment

• Primarily outpatient clinic setting with telephonic and electronic coordination components.
• May require occasional travel between clinic locations.
• Requires use of computers, telephones, and standard office equipment.

Performance Measures

• Completion and documentation of TOC within organizational timelines.
• Enrollment and ongoing management of eligible CCM patients.
• Reduction in hospital readmissions and emergency visits for managed patients.
• Improvement in clinic quality metrics (e.g., A1c control, hypertension management, preventive screenings).
• Positive patient experience and satisfaction with care coordination services.

Supervision

None

Company Benefits Overview

• Medical, Dental and Vision
• Life Insurance and Voluntary Life Insurance
• Paid Time Off
• Tuition Reimbursement, Discounts and Scholarships Programs
• Retirement Plans
• Long-Term and Short-Term Disability
• Health Savings Account
• Flexible Spending Account
• Wellness Program
• Service and Pharmacy Discounts
• Employee Assistance Program
• Holiday Pay