[Hiring] Clinical Navigator @Paradigm

Role Description

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
• Injured workers

The Clinical Navigator plays an important role in:

• Ensuring continuity of care
• Evaluating treatment appropriateness
• Escalating delays or risks
• Delivering a high-quality, customer-first experience

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.
• Evaluate 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 understanding of Paradigm organization, products, operations, and customers.
• Utilize AI tools to support day-to-day tasks, improve efficiency, and enhance output quality.

Qualifications

• RN required.
• 3-5 years Workers’ compensation and/or complex case management experience 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.

Benefits

• Health and wellness: PPO, HDHP, and HMO health insurance options with Cigna and Kaiser (CA employees only).
• Financial incentives: Competitive salaries, 401(k) matching contributions, employer-paid life and disability insurance, flexible spending and commuter accounts, and employer-matched HSA contributions.
• Vacation: Paid time off and personal holiday programs for work-life balance.
• Volunteer time: One paid day per calendar year for community engagement.
• Learning and development: Support for continual learning through the Learning Excellence at Paradigm (LEAP) program.