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The D-SNP (Dual-Eligible Special Needs Plan) Nurse Navigator is responsible for the navigation and advocacy of members who are dually eligible for both Medicare and Medicaid. These members often have multiple or complex medical and/or behavioral health, socioeconomic, and functional needs that require comprehensive care coordination services. These services may include navigation beyond the specific case or situation, providing the member with a wide spectrum of services directed at not only medical or behavioral changes but healthy lifestyles and optimal outcomes assuring quality and continuity of care within the managed care system.

Care coordination directs intervention by offering education and support, liaising with providers of medical/behavioral services and equipment to facilitate effective communication, streamline referrals, assist in developing and implementing comprehensive individualized care plans, and supporting smooth discharge planning. This is achieved through the establishment of routine follow up to monitor, evaluate, revise or close care plan interventions and goals which support ongoing communication and interaction among the interdisciplinary care team and provides opportunities to appraise cases for quality of care.   

Required:

1. Registered Nurse with at least five (5) years’ experience. Three (3) of those years may be work experience as a nurse’s aide, LPN or other appropriate position in a clinical setting.  (RN outside minimum experience may be waived for internal applicants currently employed as an LPN with written recommendation of current supervisor or manager).
2. Active Ohio or WV licensure upon hire. Ohio or West Virginia multistate licensure must be obtained within the 90-day probationary period and maintained throughout employment including compliance with State Boards of Nursing and continuing education policy. Other licensure as company expansion warrants.
3. Demonstration of excellent oral, written, telephonic and interpersonal skills.
4. Demonstration of proficient keyboarding skills and computer literacy with the ability to navigate through multiple systems.
5. Flexibility and demonstration of the ability to balance an independent and team working environment, multitask, work in a fast-paced environment, and adapt to changing processes.
6. Possession of a superior work ethic and a commitment to excellence and accountability.
7. Proven ability to exercise independent and sound judgment in decision making, utilizing all relevant information with proactive identification and resolution of issues.

Desired:

1. Utilization Management, Quality Improvement, Case Management, Disease Management, or other Managed Care experience is desirable.
2. Certification in an area of clinical expertise related to current work i.e., CDE, CCM, CMCN, Motivational Interviewing/MI Trainer, etc.

Responsbilities:

1. Coordinate and provide case management services that are safe, timely, effective, efficient, equitable, and client-centered.
2. Handle case assignments, perfrom comprehensive and thorough medical, behavioral, functional and social determinant of health assessments, develop and maintain care plans, review case progress and determine case closure.
3. Help members achieve wellness and autonomy.
4. Facilitate multiple care aspects (care coordination, condition education, utilization management, information sharing, redirection/transitional care, cost containment, benefit maximization, etc) across the care continuum inclusive of communications with all relevant multi disciplinary care team members.
5. Help members make informed decisions by acting as a resource and  advocate regarding their clinical status and treatment options.
6. Develop effective working relations within the industry and cooperate with medical/behavioral team members throughout the entire care coordination process.
7. Arrange non-benefit services with community based agengies, external social services, health and governmental agencies.
8. Thoroughly develop and document interactions with patients and families to keep track of their progress towards goals and to ensure satisfaction.
9. Record case information, complete accurately and timely all necessary referrals, reviews, assessments, careplans, notes, activies, forms and workflows to produce results evidencing adherence to case management interrater review benchmarks and NCQA, CMS and/or BMS regualatory standards as appropriate.
10. Promote quality and cost-effective interventions and outcomes in accordance with plan benefits.
11. Assess and address motivational and psychosocial issues. 
12. Adhere to professional standards as outlined by protocols, rules and regulations.

Equal Opportunity Employer

The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.