RN Nurse Navigator
On-siteWinchester, Virginia, United States or Winchester, Nevada, United States
Job Summary
Conduct comprehensive initial assessments and enroll eligible patients into the Principal Care Management program. Develop individualized, disease-specific care plans aligned with clinical guidelines and patient goals. Perform monthly PCM interactions with accurate CMS-compliant time tracking and documentation while monitoring symptoms, treatment adherence, and clinical changes to prevent deterioration. Provide medication education, lifestyle coaching, and motivational support to improve self-management. Coordinate referrals, diagnostic testing, follow-up visits, and interdisciplinary communication to address barriers to care including transportation and financial concerns. Track outcomes, engagement, and quality metrics to continuously improve chronic condition management. Participate in periodic call rotation and collaborate in quality improvement initiatives.
Required Qualifications
- Current Registered Nurse (RN) license
- Minimum 2–3 years of clinical nursing experience
- Strong knowledge of chronic condition management and patient coaching strategies
- Experience with care coordination and EMR documentation
- Strong clinical judgment, organizational skills, and the ability to build meaningful relationships with patients and providers
Desired Qualifications
- Bachelor of Science in Nursing (BSN) preferred
- Prior experience in Principal Care Management (PCM), Chronic Care Management (CCM), Case Management, or Population Health preferred
- Certification in care coordination or chronic disease management (e.g., RN-BC in Care Coordination & Transition Management) preferred
- chronic disease management preferred—cardiology, pulmonology, endocrinology, rheumatology, or similar specialties
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