Posted 1mo ago

Outpatient Nurse Navigator - ACO

@ Insight Hospital and Medical Center Chicago
Coldwater, Michigan, United States
OnsiteFull Time
Responsibilities:Manage panel, Coordinate care, Engage patients
Requirements Summary:Active RN license (Michigan); 3–5+ years clinical experience; care coordination, ambulatory care, or chronic disease management; strong communication and critical thinking.
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Job Description
Outpatient Nurse Navigator - ACO
 
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

Strong communication and critical thinking skills
 
Preferred:

Experience in ACO, population health, or value-based care

Case management experience

Familiarity with quality metrics (HEDIS, CMS, etc.)

Certification (CCM, ACM, or similar)
 
Why This Role Matters:

This is where healthcare is going.

You’ll help patients:

Stay out of the hospital

Better manage chronic conditions

Navigate the system with confidence

And you’ll do it in a role that is structured to allow you to succeed.
 
About Insight

Insight is committed to improving care beyond the hospital through strong outpatient and population health programs that prioritize outcomes, access, and patient experience.
 
Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or other status

protected by applicable law.
 
Insight is an Equal Opportunity Employer Workplace