RN Navigator​/ACO Specialist

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.

• 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,…