Nurse Navigator Medical Cost Management
About the position UNITE HERE HEALTH serves over 200,000 workers and their families in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity! The Nurse Navigator is a licensed clinical professional who supports members in navigating the healthcare system, coordinating care, and improving health outcomes. This role focuses on reducing unnecessary emergency room utilization, enhancing chronic disease management (especially for diabetes and ESRD), and promoting cost-effective care through education and network optimization. The Nurse Navigator works collaboratively with members, providers, and internal teams to address barriers to care and support population health initiatives. Responsibilities • Serve as a clinical resource and point of contact for high-risk and high-cost members, guiding them through care coordination and benefit utilization. • Educate members on chronic disease management, preventive care, and appropriate use of healthcare services, with a focus on diabetes and ESRD. • Identify and address social determinants of health (SDOH) that impact access to care and adherence to treatment plans. • Support members in locating in-network providers and facilities to reduce out-of-network and emergency room usage. • Coordinate referrals, post-discharge planning, and medication adherence strategies. • Collaborate with network case managers, social workers, and providers to ensure timely and appropriate care delivery. • Conduct outreach to at-risk populations to promote engagement in wellness programs and adherence to care plans. • Partner with community-based organizations to connect members with additional support services. • Document all member interactions and interventions in compliance with HIPAA and payer-specific guidelines. • Monitor and report trends related to gaps in care, member concerns, and program effectiveness. Requirements • 3+ years of experience in care coordination, case management, or patient navigation. • Strong understanding of health insurance plans, provider networks, and value-based care models. • Clinical experience in chronic disease management, especially diabetes and ESRD. • Excellent communication, critical thinking, and interpersonal skills. • Ability to work with diverse populations and address health equity challenges. • Proficiency in electronic health records (EHR) and payer systems. • Knowledge of community health resources and support services. • Registered Nurse (RN) license required • Certified Diabetes Educator (CDE) or equivalent experience in diabetes education. • Certification in Case Management (CCM), Public Health (CPH), or similar credential. Nice-to-haves • Spanish Bi-lingual skills (preferred). • Experience in managed care or payer settings is a plus. • BSN or higher preferred. Benefits • Medical • Dental • Vision • Paid Time-Off (PTO) • Paid Holidays • 401(k) • Short- & Long-term Disability • Pension • Life • AD&D • Flexible Spending Accounts (healthcare & dependent care) • Commuter Transit • Tuition Assistance • Employee Assistance Program (EAP) Apply tot his job