Note: The job is a remote job and is open to candidates in USA. Texicare is a mission-driven health affiliate of Texas Mutual, focused on transforming the healthcare landscape for small businesses in Texas. The Senior RN Clinical Care Navigation & Vendor Liaison Coordinator will serve as the clinical point of contact for care coordination and vendor partnerships, ensuring effective resolution of complex member care concerns.
Responsibilities
- Serve as a clinical resource and subject matter expert to internal stakeholders regarding managed care processes, care coordination workflows, utilization management practices, and member navigation challenges
- Serve as the health plan's clinical point of contact for complex care coordination, care navigation, and member care escalations
- Assess escalated cases to determine clinical context, urgency, barriers to care, and appropriate next steps
- Manage urgent, complex or high-profile member issues involving utilization management, care management, provider access, transitions of care, benefits, and healthcare navigation
- Partner with outsourced utilization management and case management vendors to facilitate timely resolution of escalated member concerns and ensure appropriate care coordination activities occur
- Monitor vendor responsiveness, follow-through, and resolution outcomes, escalating concerns as appropriate to vendor leadership and internal stakeholders
- Work with internal and external stakeholders to implement coordination of vendor processes and projects
- Coordinate with internal departments including Customer Experience, Provider Relations, Compliance, Quality, Operations, and Medical Management to support effective issue resolution
- Identify clinical, quality, access, compliance, privacy, grievance, or member safety concerns and ensure timely escalation to appropriate clinical or operational leaders
- Recognize high-risk or urgent situations requiring involvement of vendor clinical teams, Medical Directors, Behavioral Health, Compliance, Quality, or executive leadership
- Maintain accurate documentation of escalations, interventions, communications, and outcomes in accordance with HIPAA, regulatory, and organizational requirements
- Analyze escalation trends, member barriers, and vendor performance issues, recommending process improvements that enhance care coordination, member experience, and operational effectiveness
- Recommend improvements to workflows, vendor handoffs, internal scripts, documentation templates, and service-level expectations
- Draft internal policies and procedures as needed
Skills
- A bachelor's degree or any equivalent combination of education, training, and experience
- A current, unrestricted Registered Nurse (RN) licensed to practice in Texas
- At least 4 years of experience in managed care utilization management, case management, care coordination, clinical operations, complex care navigation or any equivalent combination of education, training, and experience
- Experience working with delegated clinical vendors and managed care partners, including vendor oversight, escalation management, service issue resolution, or clinical operations support
- Strong understanding of managed care processes, including utilization management, care management, care transitions, provider access, appeals and grievances, and delegated service models
- The ability to assess clinical situations, identify risks and barriers to care, determine appropriate escalation pathways, and coordinate resolution across multiple stakeholders
- Experience supporting commercial health plans, employer-sponsored health plans, and/or self-funded employer groups
- Working knowledge of NCQA, URAC, CMS, HIPAA, state insurance regulations, and healthcare privacy requirements
- Excellent communication, relationship management, documentation, organization, and problem-solving skills
- The ability to independently manage multiple priorities while maintaining attention to detail and follow-through in a fast-paced environment
Benefits
- Automatic 4% employer contribution to retirement plan
- 401k plan with 100% match up to 6%
- Flexible time off for vacation, illness, etc.
- Nine paid holidays
- Day one health, Rx, vision, and dental insurance
- Life and disability insurance
- Flexible spending account
- Pet coverage and pet Rx discounts
- Free identity theft protection
- Free 2nd medical opinion service
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