Registered Nurse Navigator - Primary Care/Family Practice

Job Description

The Registered Nurse Navigator in a primary care/family practice setting is responsible for coordinating patient-centered care across the continuum, with a focus on prevention, chronic disease management, and population health. This role partners closely with primary care providers and collaborates with interdisciplinary teams to proactively manage patient panels, close care gaps, and improve health outcomes while enhancing the patient experience. The RN Navigator serves as a key advocate for patients and families while promoting population health initiatives and compliance with regulatory standards.

Job Relationships

Reports to the Operations Manager.

Principal Responsibilities

• Manage a defined patient panel in collaboration with primary care providers

• Develop, implement, and monitor individualized care plans, especially for patients with chronic conditions (e.g., diabetes, hypertension, COPD)

• Coordinate care across settings including specialists

• Identify and proactively engage high-risk and rising-risk patients

• Assist with medication management and adherence

• Coach patients on preventive health and wellness strategies

• Engage patients in shared decision-making and goal setting

• Assisting preventive and quality care gaps (e.g., screenings, immunizations, annual wellness visits)

• Work closely with physicians, APPs, medical assistants, front office staff, and referral coordinators

• Serve as a liaison between patients, providers, and external care partners

• Support value-based care initiatives and quality programs

• Monitor and track performance metrics such as care gaps, utilization, and patient outcomes, identify opportunities for pr

• Conduct telephonic and/or electronic outreach for follow-ups, care coordination, and preventive care reminders

• Respond to patient inquiries and triage clinical concerns appropriately

• Assist in managing inbox messages and care coordination workflows within the HER

• Adhere to HIPAA guidelines

• Comply with the Springfield Clinic incident reporting policy and procedures.

• Adhere to all OSHA and Springfield Clinic training & accomplishments as required per policy.

• Provide excellent customer service and adhere to Springfield Clinic's Code of Conduct and Ethics Standards.

• Perform other job duties as assigned.

Education/Experience

• Active Registered Nurse (RN) license in the State of IL required

• Associate or Bachelor of Science in Nursing preferred

• Current CPR certification required

• 3-5 years of clinical nursing experience (primary care, ambulatory care, or care management) preferred

Licenses/Certificates

• Current CPR certification required

• Active Registered Nurse (RN) license in the State of IL required

Knowledge, Skills and Abilities

• Strong clinical assessment and critical thinking skills

• Excellent oral and written communication skills

• Ability to manage a patient panel and prioritize competing needs

• Familiarity with value-based care models

• Highly motivated and self-directed individual who can also participate well in a team environment

Working Environment

• Based in a primary care/family practice clinic

• Routinely uses standard office equipment such as computers, phones, photocopiers, and fax machines

• May require sitting and/or standing for prolonged periods of time

PHI/Privacy Level

HIPAA1