Outpatient Nurse Navigator - ACO

Outpatient Nurse Navigator - ACO Location

• On-site, Coldwater, MI A Care Management Role Designed to Work
• At
• Insight, we’ve built our
• ACO care management program with one goal: Give nurses the time and structure to impact patient outcomes. This is not a high-volume, task-driven role. Our RN Care Managers support a manageable panel of <300 high-risk patients, allowing for meaningful engagement, proactive care, and real results. If you’re tired of being stretched too thin to make a difference, this role was built differently. What You’ll Do Manage a Defined High-Risk Patient Panel Proactively manage a panel of <300 high-risk patients Build longitudinal relationships—not one-time interactions Develop and execute individualized care plans Coordinate Care
• Across the
• Continuum
• Serve as the central point of coordination between: Primary care Specialists Hospital and ED Post-acute and community services Ensure smooth transitions after hospital or ED visits Prevent Avoidable Utilization Identify early warning signs and intervene before escalation Reduce unnecessary ED visits and hospitalizations Close gaps in care and improve follow-up compliance Use Data to Drive Action Leverage risk stratification tools and EMR insights Prioritize outreach based on patient risk and need Track and improve quality and outcome metrics Engage Patients & Families Provide coaching using motivational interviewing and education Help patients navigate complex healthcare needs Address barriers including transportation, medications, and social determinants Partner with Providers Collaborate closely with primary care and specialists Align care plans and communicate patient needs effectively Support value-based care initiatives and performance goals What Makes This Role Different Manageable panel size (<300 high-risk patients) Focus on proactive care—not reactive task completion Strong collaboration with providers and care teams Opportunity to build relationships and see impact over time Designed to support value-based care success—not just documentation What Success Looks Like Reduced ED visits and hospitalizations Improved chronic disease management High patient engagement and adherence Strong provider collaboration and trust Measurable improvement in quality metrics Who You Are You’re proactive, organized, and relationship-driven.

Required

• Active RN license (Michigan) 3–5+ years of clinical experience Experience in care coordination, ambulatory care, or chronic disease management