Clinical Navigator

Clinical Navigator

Paradigm is an accountable specialty care management organization focused on improving the lives of people with complex injuries and diagnoses. The company has been a pioneer in value-based care since 1991 and has an exceptional track record of generating the very best outcomes for patients, payers, and providers. Deep clinical expertise is the foundation for every part of Paradigm's business: risk-based clinical solutions, case management, specialty networks, home health, shared decision support, and payment integrity programs.

Paradigm is seeking a Clinical Navigator to serve as a central coordination and clinical oversight resource for injured workers with complex and catastrophic workers' compensation claims. In this role, you will partner closely with case managers, clinical associates, providers, payers, vendors, key accounts, and injured workers to help remove barriers to care, support timely and medically necessary treatment, and promote positive outcomes. The Clinical Navigator plays an important role in ensuring continuity of care, evaluating treatment appropriateness, escalating delays or risks, and delivering a high-quality, customer-first experience.

The ideal candidate will have an active RN license and 35 years of workers' compensation and/or catastrophic case management experience. Experience with DME, utilization review, EMRs, care management platforms, and Microsoft Office applications is strongly preferred. This role is well-suited for a forward-thinking clinical professional who is comfortable working independently, taking initiative, and partnering collaboratively to support high-quality outcomes for injured workers.

This is a fully remote position with typical business hours; however, there may be instances when work outside of standard business hours is required based on business needs.

Responsibilities:

• Serve as the central point of coordination and clinical oversight of assigned complex and Catastrophic cases.
• Serve as the secondary level of clinical oversight and the single point of contact for Case Managers and Clinical Associates.
• Work directly with key accounts as assigned and is responsible for providing customer excellence with every interaction.
• Apply case management skills and experience with catastrophic workers' compensation to remove barriers with a strong focus on quality outcome, compliance and efficient case progression.
• Evaluates treatment appropriateness and utilization.
• Ensure home health & DME services are being performed as ordered, and continue to be clinically necessary, making recommendations based on Injured workers' needs and progress. Ensure treatment plans align with medical necessity and payer guidelines.
• Monitor IW progress and escalate delays or identified risks.
• Identify delays, risks and care gaps and escalate appropriately.
• Conduct QA on a predetermined number of referrals to ensure alignment with Care at Home guidelines and expectations.
• Collaborate with external agencies, providers, and vendors to coordinate care, facilitate communication, and ensure timely delivery of services and resources for patients as needed.
• Facilitate and lead case conferences and virtual roundtable discussions, as needed, to coordinate care, review patient progress, address barriers to treatment, and align stakeholders on care plans and next steps.
• Demonstrate a customer-first mindset by developing a broad and deep (where appropriate) understanding of Paradigm organization, products, operations, and customers. Prioritizes collaboration to meet customer needs and expectations and takes personal accountability for service quality.
• Utilizes AI tools to support day-to-day tasks, improve efficiency, and enhance output quality. Adopts new technologies as trained and applies them in alignment with established processes and guidelines.

Qualifications:

• RN required.
• 3-5 years Workers' compensation and/or complex case management, required.
• Experience with catastrophic cases, strongly preferred.
• Experience with DME, strongly preferred.
• Experience with EMRs, care management platforms, and Microsoft Office applications.
• Knowledge of Utilization Review process.
• Ability to communicate effectively and professionally with both internal and external customers.
• Must have a collaborative demeanor with a high emphasis on teamwork.
• Strong conflict resolution and problem-solving abilities.
• Strong understanding of medical terminology.
• Strong clinical assessment and critical thinking skills.
• Excellent prioritization and time-management skills.
• Strong documentation and auditing skills.
• Bilingual (English/Spanish) a plus.

Paradigm Benefits:

• Health and wellness We want our people to be and stay healthy, so we offer PPO, HDHP, and HMO health insurance options with Cigna and Kaiser (CA employees only).
• Financial incentives Paradigm's financial benefits help prepare you for the future: competitive salaries, 401(k) matching contributions, employer-paid life and disability insurance, flexible spending and commuter accounts, and employer-matched HSA contributions.
• Vacation - We believe strongly that work-life balance is good for you and for our company. Our paid time off and personal holiday programs give you the flexibility you need to live your life to the fullest.
• Volunteer time We want our employees to engage with and give back to their communities in meaningful ways. Full and part-time employees receive one paid day per calendar year.
• Learning and development: One of Paradigm's core values is expertise, so we encourage our employees to continually learn and grow. We support this in a variety of ways, including our new Learning Excellence at Paradigm (LEAP) program.

Paradigm believes that fostering a diverse and inclusive workplace is central to our mission of helping more people and transforming lives. We're striving to build a culture that better reflects the society we live in and empowers our team to deliver the highest levels of compassion and care to those we serve. For us, achieving this goal requires a workforce that respectfully embraces differences and commits to positive change, creating an environment where everyone is able to bring their whole self to work.

Paradigm complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact Leave Management at View email address on click.appcast.io.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.