Navigator RN

CHI LakeWood Health provides long-term care, family practice-clinic, 15-bed critical-access hospital, public health and assisted living services. Nestled in Baudette, MN, just minutes from Lake of the Woods and Zippel Bay State Park. Enjoy nature's playground, lake living, trails, unique shopping, and dining! We serve patients and their loved ones in Lake of the Woods County and the surrounding area. Check out the link for more info on Baudette, MN https://www.ci.baudette.mn.us/.

As our RN Navigator, you will work collaboratively with physicians, staff and other health care professionals to provide a medical home and care coordination across the health care continuum for all patients within the physician office setting and is an integral member of the health care team who works to ensure safety, best practice and high quality standards of care are maintained.

Every day you will be responsible for coordinating a wide range of self-management support and disease registry activities for the clinic's entire patient population.

To be successful in this role, you will provide program oversight, registry maintenance, quality reporting, grant support, Medicare wellness visits, chart reviews, care transitions and behavioral coaching. 

• Manage the Remote Patient Monitoring (RPM) program, utilizing real-time data to identify trends, intervene early, and improve outcomes for chronic disease patients
• Maintain the disease registry database, ensuring data integrity and identifying patients overdue for care, labs, or specialty referrals
• Generate and analyze performance reports for providers and clinic leadership to track progress against clinical goals (e.g., BP and glucose control)
• Serve as a core member of the Rural Health Transformation Fund team, implementing grant-related initiatives and tracking key metrics for success
• Coordinate and conduct Medicare Annual Wellness Visits (AWVs), ensuring comprehensive health risk assessments, personalized prevention plans, and documentation meet CMS requirements
• Perform comprehensive pre-visit chart reviews to identify gaps in preventive health, immunizations, and chronic care, initiating standing orders where appropriate to optimize provider efficiency

Required

• Associate Degree in Nursing
• Registered Nurse: MN

Preferred

• Bachelor Degree in Nursing