Registered Nurse Navigator at UNITE HERE HEALTH – Las Vegas, Nevada

“UNITE HERE HEALTH serves 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!”

This is a Nevada Health Solutions position.

PURPOSE

The Medical Management department is participant focused and strives to provide the best possible care for the participants through Utilization Review and Utilization Management services, Care Coordination and Outreach. The Department is designed to ensure delivery of high-quality, cost-efficient healthcare for our participants and families through coordinating care, providing detailed discharge plans, advising participants of different programs available.

The RN Navigator is responsible for conducting utilization management activities in accordance with Utilization Management policies and procedures and URAC Guidelines. The position responsibilities include the management of medical costs through timely prospective, concurrent and retrospective review activities and promoting cost-effective care through education and network optimization. The RN Navigator 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), The Nurse Navigator works collaboratively with members, providers, and internal teams to address barriers to care and support population health initiatives.

ESSENTIAL JOB FUNCTIONS AND DUTIES

• Serve as a clinical resource and point of contact for high-risk and high-cost members, guiding them through care coordination and benefit utilization.
• Provide Utilization Review within URAC timelines and expectations
• Work with participants of all ages in the acute hospital and lower level of care settings (LTAC, SNF, Rehab) to help them through the continuum of care
• Responsible for continuous communication with all parties involved in the in-patient plan of care and decision-making to determine medical necessity and appropriateness of care for service utilization and expense
• Use critical thinking skills to offer alternatives to care that has been determined not medically necessary
• Redirects care to be contracted service providers per guidelines
• Maintains productivity expectations
• Promotes alternative care programs and research available options including costs and appropriateness of patient placement in collaboration with plan benefits
• Communicates directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services
• Coordinate and attend family conferences for difficult discharge planning i.e., hospice, long term care, non-compliance
• Communicates directly with the designated medical director regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues
• Recommends, coordinates and educates providers regarding alternative care options
• 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.
• Manage High Dollar Claim reports to confirm authorization on file and conduct outreach to at-risk populations to promote engagement in wellness programs and adherence to care plans.
• Maintains courteous, professional attitude when working with the Client’s staff, hospital and physician providers, and all ancillary providers
• Identifies and communicate all catastrophic and high-risk cases for case management referral
• Active participation in team meetings, JOC’s, and weekly Medical Rounds with Medical Director and team
• Assist management in development of protocols and procedures as they relate to UM/CM
• 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.
• Contributes ideas to plans and achieving department goals
• Exemplifies the Fund’s BETTER Values and professional effectiveness dimensions in contributing to a respectful, trusting, and engaged culture of diversity and inclusion
• Performs other duties as assigned within the scope of responsibilities and requirements of the job
• Performs Essential Job Functions and Duties with or without reasonable accommodation
  

ESSENTIAL QUALIFICATIONS

Years of Experience and Knowledge

• 3+ years of experience in care coordination, case management, or patient navigation.
• Minimum 2 years of experience in utilization review, quality assurance, discharge planning or other cost management programs required,
• Minimum two years directly related experience using InterQual or Milliman criteria or healthcare criteria preferred

Education, Licenses, and Certifications

• Registered Nurse (RN) license required
• BSN or higher preferred.
• Required: Unrestricted active RN License in the following states: Nevada, Oklahoma, and Texas
• Willingness and ability to obtain a license in other States as may be required by the Fund

Skills and Abilities

• 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.
• Bilingual language skills are preferred.
• Experience in managed care or payer settings is a plus.
• Knowledge of community health resources and support services.

Salary range for this position: $93,900~$117,300. Actual base salary may vary based upon, but not limited to: relevant experience, qualifications, expertise, certifications, licenses, education or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location.

Work Schedule (may vary to meet business needs): Monday~Friday, 7.5 hours per day (37.5 hours per week) with work-from-home arrangement.

Benefits: We reward great work with great benefits, including but not limited to: Medical, Dental, Vision, Paid Time-Off (PTO), Paid Holidays, 401(k), Pension, Short- & Long-term Disability, Life, AD&D, Flexible Spending Accounts (healthcare & dependent care), Commuter Transit, Tuition Assistance, and Employee Assistance Program (EAP).

#LI-REMOTE