RN Telehealth Full-time
Blue Ridge Care

RN Nurse Navigator

Blue Ridge Care Winchester, VA 22601, US

$10,000 Sign-On Bonus – Join Blue Ridge Care Today!

Your neighbors need you. Your nursing skills can change lives.

Join Blue Ridge Care and become a Future Maker—where your compassion and clinical expertise help patients confidently manage complex chronic conditions and improve their quality of life every day.

Our mission is simple yet powerful: “Delivering extraordinary care to improve life’s journey.” As a mission-driven, not-for-profit healthcare system, we provide integrated services in hospice, serious illness care, PACE, community thrift shops, and grief support—serving our community with heart, hope, and respect.

About the Role

We’re seeking a compassionate Registered Nurse (RN) to serve as a Nurse Navigator – Principal Care Management (PCM). In this role, you will provide comprehensive, patient-centered care coordination for individuals living with a high-risk, complex chronic condition requiring intensive clinical oversight.

As the primary clinical contact for enrolled patients, you’ll create proactive, personalized care plans that improve outcomes, reduce fragmentation of care, and empower patients to better manage their health. You’ll collaborate closely with providers and interdisciplinary partners to ensure care is coordinated, compliant, and meaningful.

How You’ll Make a Difference

  • Identify and enroll eligible patients into the PCM program and complete comprehensive initial assessments.

  • Develop individualized, disease-specific care plans aligned with clinical guidelines and patient goals.

  • Conduct monthly PCM interactions with accurate CMS-compliant time tracking and documentation.

  • Monitor symptoms, treatment adherence, labs, and clinical changes—intervening early to prevent deterioration.

  • Provide medication education, lifestyle coaching, and motivational support to improve self-management.

  • Coordinate referrals, diagnostic testing, follow-up visits, and interdisciplinary communication.

  • Address barriers to care including transportation, social determinants of health, and financial concerns.

  • Track outcomes, engagement, and quality metrics to continuously improve chronic condition management.

  • Participate in periodic call rotation and collaborate in quality improvement initiatives.

What You’ll Bring

  • Current Registered Nurse (RN) license.

  • Minimum 2–3 years of clinical nursing experience (chronic disease management preferred—cardiology, pulmonology, endocrinology, rheumatology, or similar specialties).

  • Strong knowledge of chronic condition management and patient coaching strategies.

  • Experience with care coordination and EMR documentation.

  • Bachelor of Science in Nursing (BSN) preferred.

  • Prior experience in Principal Care Management (PCM), Chronic Care Management (CCM), Case Management, or Population Health preferred.

  • Certification in care coordination or chronic disease management (e.g., RN-BC in Care Coordination & Transition Management) preferred.

  • Strong clinical judgment, organizational skills, and the ability to build meaningful relationships with patients and providers.

  • A proactive, compassionate spirit ready to serve your community and improve life’s journey.

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For facilities with specialty accreditation requirements: 1. Completion of annual required education related to specialty accreditation as defined by accreditation standards. Training may be completed through CBLs, trainings, In-services, and competency validation. PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. The National Institute for Occupational Safety and Health recommends minimizing the need for employees to manually lift patients, and limit safe patient handling to 35 pounds. All transfers, lifts and re-positioning will be completed utilizing the lift equipment and/or other patient handling aids as indicated by the patient’s profile and appropriate algorithms. 2. Heavy/Hard work : Work requires strength and/or stamina, lifting, moving, stooping, reaching, standing, walking, and carrying of materials and equipment weighing 40+lbs. 3. Visual acuity must be within normal range. 4. Hearing within normal range is required (i.e. to assess breath sounds, bowel sounds, apical pulse, monitors, etc.) WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. Working protracted or irregular hours. 2. Working around biohazards. 3. Working around infectious diseases. 4. Working with or near the deceased. 5. Working with hands in water. 6. Working with electrical hazards associated with patient care equipment. SKILLS AND ABILITIES: 1. Possesses the interpersonal skills to positively and effectively communicate, negotiate, and resolve conflict. 2. Uses competent clinical practice and critical thinking skills to efficiently deliver patient care with all health care providers while maximizing efficient use of resources. 3. Ability to be flexible in response to changes in work volume, staff and scheduling changes. 4. Ability to work successfully under highly stressful conditions and capable of adapting to varying workloads and work assignments on a constant basis. The CAPE program is a system-wide clinical advancement program (clinical ladder) to enhance professional development, provide a reward system for quality clinical performance, promote quality nursing, and improve job satisfaction for inpatient direct care nurses. To apply for the next level, the CAPE nurse must meet the requirements of their current level. They must also meet the required years of nursing experience, degree, and certification to apply for the next level. In addition, nurses who are approved for levels 3, 4, 5, or 6 must complete and submit five competencies on an annual basis to maintain their current level. Level 1 No experience required All graduate nurses with less than 12 months of experience enter at Level one with a diploma, ADN, BSN, or higher Level 2 Meets requirements for previous level One year of experience. Level 3 Meets requirements for previous levels Two years of experience, plus one specialty certification Certification is Preferred but not required Required competencies to include demonstration of regularly being a charge nurse and/or precepting new staff or nursing students Level 4 Available to those with a BSN or higher or nurses with ADN/diploma with 5 years of experience one specialty certification is required Required competencies to include demonstration of regularly being a charge nurse and/or precepting new staff or nursing students Required competencies to include demonstration of participation in QI and/or shared governance at the unit level Level 5 Available to those with an MSN or higher with 4 years of experience, or nurses with a BSN with 4 years of experience and a health-related Master’s Degree, or nurses with a BSN and 5 years of experience One specialty certification is required Required competencies to include demonstration of regularly being a charge nurse and/or precepting new staff or nursing students Required competencies to include demonstration of participation in QI and shared governance at the organization level Level 6 Available to those with an MSN or higher degree with 7 or more years of experience. Consideration is given to other health-related advanced degrees that would assist with direct patient care at the bedside One specialty certification is required Required competencies to include demonstration of regularly being a charge nurse and/or precepting new staff or nursing students Required competencies to include demonstration of participation in QI and shared governance at the system level Additional Job Description: 7p-7a everyother weekend Scheduled Weekly Hours: 36 Shift: Night (United States of America) Exempt/Non-Exempt: United States of America (Non-Exempt) Company: BMC Berkeley Medical Center Cost Center: 51 BMC Nursing Emergency Services Address: 2500 Hospital Drive Martinsburg West Virginia Equal Opportunity Employer West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.