Chronic Disease Nurse Navigator

Job Number: 22-231-11627

Registered Nurse Job Summary: The Chronic Disease Nurse Navigator offers individualized assistance to clients, families, and caregivers to help overcome healthcare barriers. Initially, clinical focus will be on pre-diabetes/diabetes management but may expand in the future to include other chronic illnesses that disproportionately affect individuals with psychiatric and substance use disorders. In this role, the RN will facilitate communication with medical providers, provide education to high-risk clients, coordinate medical services, and promote optimal resource allocation while balancing clinical quality and data collection responsibilities. Assists clients as they transition through multiple healthcare settings while providing high risk care management.

Hybrid schedule will include both telehealth and community-based responsibilities.


  • Assesses client needs upon initial encounter and periodically throughout navigation. Matches unmet needs with appropriate services, referrals and support services, such as dietitians, medical providers (primary care and specialists), social work and pharmacy. Acts as a liaison between clients, families, caregivers and the providers to optimize client outcomes.
  • Identifies high risk clients who would benefit from chronic care management and works collaboratively with the primary care provider, client, and other clinical team members to develop an individualized client-centered plan of care.
  • Participates in coordination of the plan of care with the multidisciplinary team, promoting timely follow-up on evaluation and treatment of chronic disease exacerbations and complications, as needed. Facilitates timely scheduling of appointments, referrals, diagnostic testing, and procedures to expedite the plan of care and to promote continuity and quality care.
  • Utilizes appropriate assessment tools (e.g., Diabetes Risk Assessment, HRQoL Measures) to promote a consistent, holistic plan of care.
  • Builds therapeutic and trusting relationships with clients, families, and caregivers through effective communication and listening skills. Utilizes motivational interviewing techniques to assist clients in meeting their goals and managing their chronic disease.
  • Participates in the tracking of metrics and physical health outcomes. Focuses on prevention measures consistent with established guidelines and care process models and works toward continuously improving quality metrics and closing care gaps.
  • Demonstrates effective communication with peers, members of the multidisciplinary healthcare team, and community organizations and resources.

Knowledge, Skills and Abilities:

  • Possess and maintain computer skills to include working knowledge of Word, Outlook, Excel, PowerPoint, and ability to learn other software as needed. Knowledge of electronic health records preferred.
  • Must function with a high degree of autonomy, communication and interpersonal skill. Must understand the health care continuum and have the ability to solve complex problems.
  • Extensive knowledge of diabetes care guidelines preferred.
  • Demonstrated ability to work collaboratively with multidisciplinary care teams and individuals with multiple comorbidities including psychiatric disorders.
  • Knowledge of professional practice standards, regulatory requirements, and systems operations required.
  • Nursing experience in a variety of care settings (Outpatient Clinic, SNF, Home Health, and Acute Care) preferred.
  • Ability to evaluate clinical outcomes across a variety of primary care settings and familiarity with diabetes and lipid management, including dietary assessment and medication reconciliation preferred.

Registered Nurse Education:


  • Graduation from an accredited four-year college or university with major course work in nursing. 

Registered Nurse License: 


  • Current and valid driver's license and a clean driving record. 
  • Licensed as a Registered Nurse in the State of Texas.

Hours:  Full-time, Monday-Friday. 8:00 am - 6:00 pm (30 hours per week) initially but may evolve into full-time position in the future.

Salary:  $36.41 - $46.41 hourly depending on licensed experience.

Position is eligible for differential pay.

  • Second Shift: $3.25

  • Third Shift: $4.25

  • Weekend Shift: $5.00

Sign-on incentive: Integral Care looking to grow our teams with talented and caring people just like you. Currently, we are offering a $2,000 sign-on incentive for all newly hired employees! All newly hired employees will receive $1,000 on their first paycheck and $1,000 on the paycheck following their six-month anniversary. 

Why join us: Integral Care has proudly served Travis County residents for the past 50 years. As the largest provider of behavioral health services in Travis County, we are dedicated to improving the lives of adults and children living with mental illness, substance use disorder and intellectual and developmental disabilities. 

By joining our team, you will find rewarding work every day alongside people who have as much compassion as you. Join us and together we can help improve the quality of life for the people we serve. Imagine your career at Integral Care!

Employee Benefits: 

  • Medical, Dental and Vision insurance

  • Generous vacation/holiday/sick leave 

  • Life and Short-term/Long-term Disability Insurance

  • Employee Assistance Program (EAP)

  • 403(b) retirement account

  • 401(a) employer contribution retirement account

  • Gold's gym membership discount

  • Mileage reimbursement

Integral Care strives to maintain a diverse workforce. We encourage all to apply, including those who have knowledge and/or experience working with underserved populations, including Asian and Pacific Islander, Black/African American, Hispanic/Latino, and LGBTQA communities.

All qualified applicants will receive consideration for employment without regard to race, creed, color, religion, national origin, sexual orientation, gender identity, disability, veteran status, sex or age.

For specific positions, additional compensation may be available to those who are bilingual in both English and one of the following languages:  Spanish, Chinese, Vietnamese, Korean, or Burmese. (PM16)

RN Keywords: Registered Nurse, RN, Psychiatric Nurse, Psych Nurse, Staff Nurse, Charge Nurse, RN Case Manager, RN Field Nurse, Mental Health Nurse