Nurse Advocate

The Nurse Advocate serves as the Trust’s clinical liaison to members, dependents, providers, and vendors. The role ensures members receive timely, appropriate, and high‑quality care while supporting the Trust’s cost‑management strategies, plan design, and fiduciary obligations. This position blends clinical judgment, care navigation, education, and data‑driven outreach to improve outcomes and reduce avoidable spend in a self‑funded environment.

Member Advocacy & Care Navigation: Provide one‑on‑one clinical guidance to members and families regarding diagnoses, treatment options, specialist referrals, and care pathways. Assist members in navigating complex medical situations, including chronic conditions, cancer care, high‑cost procedures, and post‑hospital transitions. Coordinate with providers to ensure continuity of care, timely follow‑up, and adherence to evidence‑based guidelines. Support members in understanding plan benefits, coverage rules, and available Trust‑sponsored programs. Clinical Case Management & Cost Stewardship: Identify high‑risk, high‑cost, or rising‑risk members through data reports, and vendor analytics. Conduct proactive outreach to support early intervention, reduce avoidable ER visits, and improve chronic disease management. Collaborate with the TPA’s medical management team to review complex cases, prior authorizations, and utilization trends. Recommend care pathways, centers of excellence, or alternative treatment options aligned with quality and cost‑effectiveness. Provider & Vendor Coordination: Serve as the Trust’s clinical point of contact with TPAs, PBMs, wellness vendors, behavioral health partners, and specialty networks. Participate in case rounds, utilization review discussions, and appeals/denials processes. Support integration of clinical programs such as telehealth, mental health services, wellness initiatives, and disease‑specific programs. Member Education & Outreach: Develop and deliver educational materials, workshops, and communications on preventive care, chronic disease management, and health literacy. Provide targeted outreach to improve compliance with screenings, vaccinations, and Trust‑sponsored wellness programs. Support member engagement strategies that improve outcomes and reduce long‑term plan costs. Compliance, Reporting & Quality Improvement: Maintain accurate, confidential case notes and documentation consistent with HIPAA and Trust policies. Track and report key metrics such as case outcomes, member engagement, cost avoidance, and program utilization. Identify trends and recommend improvements to plan design, vendor programs, or clinical processes. Participate in annual plan evaluation, renewal discussions, and strategic planning with Trust leadership.