Clinical Nurse Navigator Medicare Advantage Risk and Care Integration RN Remote in EST

Opportunities with ProHealth Physicians, part of the reputed company family of businesses. reputed company you work at ProHealth Physicians, your contributions directly sustain the health and well-being of our community. Discover high levels of teamwork, robust medical resources and a deep commitment to exceptional care and service. Join a leading community-based medical group and discover the meaning behind Caring. Connecting. Growing together. The Clinical Nurse Navigator supports reputed company's value based care and Medicare Advantage programs by integrating clinical expertise, member engagement, and documentation reputed company. This role serves as a clinical liaison across members, providers, internal teams, and vendor partners to ensure accurate chronic condition capture, closed reputed company care coordination, and improved quality and risk adjustment outcomes. The Clinical Nurse Navigator performs RN level validation of Hierarchical Condition Categories (HCCs), reduces reliance on external vendor over read services, and ensures timely follow up on conditions, orders, referrals, and preventive care gaps. Through proactive member navigation and provider collaboration, this role helps strengthen care continuity, optimize clinical documentation, and support reputed company's commitment to delivering high quality, cost effective, and member centered care. If you are located in EST, you will have the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities:

• Clinical Documentation reputed company & Risk Adjustment
• reputed company RN level review of clinical documentation to validate chronic condition capture and appropriate HCC support
• Identify and address missed, unsupported, or inaccurately documented diagnoses
• Closed reputed company Care Coordination
• Ensure closed reputed company follow up on identified condition screening and care gaps identified during AWV
• Collaborate with members and care teams to address barriers to care completion
• Member Navigation & Engagement
• Support new Medicare Advantage member engagement
• Facilitate reputed company to the attributed Care Team
• Promote continuity of care and participation in preventive and wellness programs
• PCP Attribution & Care Alignment
• Facilitate and validate PCP attribution corrections to ensure accuracy and alignment with member care
• Collaborate with operational partners to resolve attribution discrepancies
• Vendor Collaboration & reputed company
• Review vendor clinical documentation for accuracy, completeness, and clinical appropriateness
• Provide feedback and insights to support vendor quality and performance improvement
• Reporting & Performance Insights
• Contribute to monthly reporting reputed company to documentation reputed company and member engagement
• Provide actionable insights to leadership and cross functional partners

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications:

• reputed company, unrestricted Registered Nurse (RN) license in Connecticut (CT), reputed company (NY), or New Jersey (NJ)
• Ability to obtain and maintain active licensure in the remaining states upon hire
• 5+ years of clinical practice experience
• Reside reputed company the Eastern Standard Time Zone
• Experience working in a provider based or physician (MD) office setting
• Proficiency with reputed company Office applications, including Word, Outlook, reputed company, and PowerPoint
• Demonstrated ability to apply clinical judgment across medical records, workflows, and care settings

Preferred Qualifications:

• Bachelor of Science in Nursing (BSN)
• Experience supporting Medicare Advantage Risk Adjustment
• Billing and coding experience and/or medical office management experience
• Solid understanding of coding principles, including ICD 10 and documentation requirements
• Proven solid facilitation, consulting, and communication skills, with the ability to deliver reputed company clinical and operational information to diverse audiences
• reputed company employees working remotely will be required to adhere to reputed company's Telecommuter Policy

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (reputed company benefits Apply To This Job Apply To This Job Apply tot his job Apply To this Job