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Nurse Navigator (RN) - ASC Ortho/Plastics/Pain - Full Time

Are you looking for a career that offers both purpose and the opportunity for growth? Parkland Community Health Plan (PCHP) is a proud member of the Parkland Health family. PCHP is a Medicaid Managed Care Organization servicing Texas Medicaid and CHIP in the Dallas Service Area. PCHP works to fulfill of our mission by empowering members to live healthier lives. By joining PCHP, you become part of a team focused on innovation, person-centered care, and fostering stronger communities. As we continue to expand our services, we offer opportunities for you to grow in your career while making a meaningful impact. Join us and work alongside a talented team where healthcare is more than just a job—it’s a passion to serve and improve lives every day. Primary Purpose Identifies patient financial/medical eligibility, and develops, implements, monitors, and communicates individual patient plans of care to patients, families, and PHHS staff in order to ensure efficient, cost effective, quality patient care and compliance with program/PHHS policies and procedures. Minimum Specifications Education - Must be a graduate from an accredited school of nursing. Experience - Two (2) years of nursing experience Equivalent Education and/or Experience - None Certification/Registration/Licensure - Must have current, valid RN license or temporary RN license from the Texas Board of Nursing; or, valid Compact RN license. - Must have current healthcare provider BLS for Healthcare Providers certification from one of the following: American Heart Association American Red Cross Military Training Network Skills or Special Abilities - Provides care to assigned patient population in accordance with the current State of Texas Nurse Practice Act, established protocols, multidisciplinary plan of care and clinical area specific standards. - Must be able to communicate and collaborate effectively with a diverse group of patients, families and healthcare staff. - Must be able to demonstrate a working knowledge of specific patient populations and be able to demonstrate knowledge of disease processes affecting this group. - Must be able to demonstrate a working knowledge of PC operations and the ability to use word processing software in a Windows environment. - Must be able to demonstrate a working knowledge of laws and regulations governing Medicare, Medicaid and other funding sources. - Must be self-directed and capable of priority setting and problem solving. - Must be able to demonstrate patient center/patient valued behaviors. Responsibilities 1. Conducts comprehensive assessment of patient in person, by telephone or by review of medical records. Gathers information from patient records and consults clinical team as needed. Identifies financial and medical status by reviewing patients diagnosis, recommended treatment, funding sources and special needs according to PHHS policies and procedures. 2. Develops patient plan of care and communicates the plan to patients and their families. May refer patients to identified primary care providers as needed. Oversees implementation of plan of care, ensures scheduling of appointments and provides relevant clinical information to primary care/ referring provider/specialty provider to ensure quality and continuity of patient care. Completes relevant documentation, intervening to optimize use of resources for cost effective healthcare. 3. Educates the patient on their diagnosis, treatment plan, referral process, clinic criteria, authorization process, payor/plan coverage, funding sources and community resources available to the patient. 4. Reviews referrals to primary/specialty clinics for appropriateness based on established clinic criteria. Reviews all available clinical data to ensure appropriate decision making. May facilitate required clinical and diagnostic work up to ensure that it is completed prior to approving the patient for a specialty appointment. Refers unfunded patients for financial counseling. Determines priority of appointment scheduling, contacting providers and others as needed for overbook approval. 5. Serves as a patient advocate, focusing on patients’ needs, rights, confidentiality and cultural preferences. Serves as a resource person for specific clinical and patient care issues, helping to negotiate desirable patient outcomes. Serves as a liaison between provider and patient/family to facilitate communication and services. 6. Uses a computerized database to verify and update patient financial information and complete appropriate documentation when applicable. Maintains knowledge regarding all payors/plans and potential funding sources. Communicates with other PHHS staff including pre-visit planning, registration, clinic staff, care management staff and providers to ensure reimbursement of clinic visits and procedures. Ensures authorization of visits to clinics for assigned patients as required. May refer outpatients who are out of network back to in network providers. Manages clinical denials, educating referring providers on clinic and payor requirements. 7. Promotes collaborative practice among patients, their families and multidisciplinary health care team members by attending meetings and acting as a consultative resource to physicians and PHHS staff. Maintains a positive relationship with all PHHS internal and external customers. Schedules inpatient and/or ambulatory operative procedures for assigned population based on medical necessity. Evaluates medical necessity of procedures ordered and ensures appropriate level of care for admissions. Coordinates pre-operative work up activities for assigned patients to reduce surgical delays/ cancellations. Ensures that each patient receives optimum care and that PHHS is adequately reimbursed for patient services. 8. Oncology Services Only: Will maintain current Commission on Cancer specific certification in the nurse’s specialty by an accredited certification program or will continue ongoing education by earning 12 cancer-related continuing education nursing contract hours per year or 36 cancer-related continuing education nursing contract hours each accreditation cycle (3 years). Parkland Community Health Plan (PCHP) prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.