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naviHealth, Inc. Cross-Market Care Coordinator in Iowa

Job Summary

The Cross-Market Care Coordinator works in a dual role as a Skilled Inpatient Care Coordinator (SICC) and Transitional Care Coordinator (TCC). The Cross-Market Care Coordinator plays an integral role in the patient’s journey towards better well-being by serving as the communication link between the patient and their interdisciplinary health care team in both the acute care and post-acute care (PAC) settings.

The Care Coordinator is responsible for identifying the appropriate first PAC setting in acute and utilizing nH Predict to align expectations and discharge planning efforts in PAC. In both settings, the Care Coordinator evaluates a defined population for transitional needs post-discharge to improve outcomes. The Care Coordinator engages hospital care teams, physicians, post-acute care providers, and patients and their families/caregivers while providing objective information and support throughout the care continuum focusing on safe transitions of care and improving the patient journey. A successful Cross-Market Care Coordinator demonstrates a high degree of adaptability and flexibility and is one whose skills and proficiency allow for quick integration – in part or in whole – into an existing market or client model.


  • Perform SICC and/or TCC responsibilities telephonically as directed by leadership.

  • Engage and collaborate with in-market leaders as needed based on current assignment or as directed by leadership. This could include in-market Clinical Team Managers or Provider Relations Managers.

  • Participate in the collaborative patient care process to assess, plan, implement, coordinate, monitor, and evaluate options and services required to meet patients’ post-acute health needs, using communication and available resources to promote quality, cost-effective outcomes.

  • Maintain nH Coordinate case documentation per established standards.

  • Provide telephonic post-discharge support to assist a defined population of patients in meeting short-term needs to prevent readmissions. This may include

  • collaboration with other care team members such as home health providers to avoid redundant telephonic follow up and coordinate care.

  • Address end of life issues including hospice and palliative care options.

  • Practice cultural competency with awareness and respect for diversity.

  • Facilitate the development of culturally sensitive individualized transitional care plans for services that including clinical, psycho-social, and environmental needs. Monitor and evaluate the effectiveness of plans and make recommendations for changes in the transitional care plan that incorporates transitional needs, as indicated.

  • Provide individualized evidence-based condition-specific patient education directed at self-care and reduction of exacerbations. Education is delivered at the appropriate health literacy level in a culturally sensitive manner.

  • Perform all Transitional Care Coordinator (TCC) and/or Skilled Inpatient Care Coordinator (SICC) specific functions as assigned.

  • Assist in identifying patients who qualify for the BPCI-A program.

  • May perform functional assessments on a defined population of patients using clinical skills and proprietary PAC management workflow system and functionally based assessment technology tools. Provide outcome targets to the appropriate audience.

  • Utilize naviHealth proprietary technology and industry-standard evidence-based tools, such as nH Predict™ and InterQual, for consideration of the appropriate level of care, readmission risk, and needed interventions.

  • Collaborate effectively with patients’ interdisciplinary health care teams to coordinate the target length of stay and an optimal transition plan to the most appropriate PAC setting and connecting patients to community resources and additional services as appropriate. The health care team includes physicians, health plan UM/CM Nurse, hospital discharge planners, referral coordinators, etc.

  • Communicate with hospital case management and physicians on identified patients that do not meet criteria and assist with developing appropriate discharge setting as needed.

  • Participate in weekly readmission and other type rounds as needed based upon opportunities.

  • Attend weekly SNF Rounds and other meetings.

  • Participate in SNF IDT (Interdisciplinary Teams Rounds) weekly providing accurate and up to date information to the naviHealth Management team.

  • Engage with patients, families, or caregivers either telephonically or on-site weekly and as needed including attending patient/family care conferences.

  • Manage assigned caseload in an efficient and effective manner utilizing good time management skills.

  • Keep current on federal and state regulatory policies related to utilization management and care coordination (CMS guidelines, Health Plan policies, and benefits).

  • Pursue and maintain multi-state licensure to meet business needs.

  • Initiate and maintain access to multiple Electronic Medical Record (EMR) platforms.

  • Adhere to organizational departmental policies and procedures.

  • Adhere to all local, state, and federal regulatory policies and procedures.

  • Promote a positive attitude and work environment.

  • Attend naviHealth meetings as requested.

  • Hold patients’ protected health information confidential as required by applicable laws, regulations, or agency/institution procedures.

  • Perform other duties and responsibilities as required, assigned, or requested.


  • Active, unrestricted registered clinical license required – Registered Nurse, Physical Therapist, or Occupational Therapist

  • 3 - 5 years of clinical experience required

  • At least 2 years of case management experience preferred

  • Patient education background, rehabilitation, and/or home health nursing experience a plus

  • Experience working with geriatric population preferred

  • Exceptional verbal and written interpersonal and communication skills

  • Strong problem solving, conflict resolution, and negotiating skills

  • Proficient with Microsoft Office applications including Word, Excel, and PowerPoint

  • Independent problem identification/resolution and decision-making skills

  • Detail-oriented

  • Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously

  • Team player

Work Conditions and Physical Requirements

  • Ability to establish a home office workspace

  • Ability to manipulate laptop computer (or similar hardware) between office and site settings

  • Ability to view screen and enter data into a laptop computer (or similar hardware) within a standard period of time

  • Ability to communicate with clients and team members including use of cellular phone or comparable communication device

  • Ability to remain stationary for extended periods (1- 2 hours)

  • Travel requirements

  • Role is primarily remote/telephonic but may require travel as directed by manager

About naviHealth

naviHealth is improving the healthcare experience for seniors to live more fulfilling lives. For nearly a decade, naviHealth has been a trusted partner for the nation’s top health plans, health systems, and at-risk physician groups navigating the shift from volume to value. Powered by a predictive technology and decision support platform that provides clinicians and care teams with evidence-based protocols, naviHealth’s high-touch, proven care model fully supports patients from pre-acute through to the home. With naviHealth, patients can enjoy more days at home, and healthcare providers and health plans can significantly reduce costs specific to unnecessary care and readmissions. For more information about naviHealth, visit

Our Purpose

Improving the healthcare experience for seniors to live a more fulfilling life

Our Values

Rooted in respect

Guided by purpose

Devoted to service

Energized by impact

The above statements are intended to describe the general nature and level of work performed by colleagues assigned to this job. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications. naviHealth reserves the right to amend and change responsibilities to meet business and organizational needs as necessary.

naviHealth is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or any other protected status under applicable laws and will not be discriminated against on the basis of disability.

Requisition ID: 2021-6535

Location Type: Field / Office / Virtual: Virtual (Home Office)