What are the responsibilities and job description for the Outpatient Nurse Navigator - ACO position at Insight Hospital and Medical Center?
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
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