RN Nurse Navigator: Chronic Care Coach & Coordinator

Blue Ridge Care; Winchester (VA); On-site; USD 85,000 - 110,000; Full time

Benefits offered by this job

Sign-on bonus $10,000

Job summary

Blue Ridge Care is seeking a compassionate Registered Nurse (RN) to serve as a Nurse Navigator – Principal Care Management (PCM). You will provide comprehensive, patient-centered care coordination for individuals with high-risk, complex chronic conditions and intensive clinical oversight.

You will be the primary clinical contact for enrolled patients, creating proactive care plans and ensuring care is coordinated, compliant, and meaningful in collaboration with providers and interdisciplinary

Qualifications

• Current RN license required.
• 2–3 years clinical nursing experience in chronic disease management preferred.
• BSN preferred.
• Experience in PCM/CCM or Population Health is a plus.
• Certification in care coordination or chronic disease management preferred.

Responsibilities

• Identify and enroll eligible patients into PCM program.
• Develop individualized care plans aligned with guidelines and goals.
• Conduct monthly PCM interactions with CMS-compliant documentation.
• Monitor symptoms, labs, and clinical changes; intervene early.
• Provide medication education and lifestyle coaching.
• Coordinate referrals, testing, and follow-up with care team.
• Address barriers to care including transportation and social determinants.
• Track outcomes and participate in quality improvement.

Skills

Chronic disease mgmt

Care coordination

EMR documentation

Patient coaching

Clinical judgment

Education

BSN preferred

RN license

RN-BC in Care Coordination

Tools

EMR systems

Job description

Blue Ridge Care is seeking a compassionate Registered Nurse (RN) to serve as a Nurse Navigator – Principal Care Management (PCM). You will provide comprehensive, patient-centered care coordination for individuals with high-risk, complex chronic conditions and intensive clinical oversight.

You will be the primary clinical contact for enrolled patients, creating proactive care plans and ensuring care is coordinated, compliant, and meaningful in collaboration with providers and interdisciplinary