Senior RN Clinical Care Navigation & Vendor Liaison Coordinator

About Texicare

Founded in 2023 as a mission-driven health affiliate of Texas Mutual, Texicare was created by a group of seasoned healthcare professionals, and is headquartered in Austin, Texas. 

Texicare is committed to changing the healthcare landscape by providing small businesses with innovative solutions that increase access to easy-to-use, more affordable, quality health care for Texans and their families. Texicare’s vision is to transform the healthcare ecosystem for the better, helping to create a healthier and happier Texas.  Our healthcare plans were designed to be used, to remove barriers to care, to truly make a difference in people’s lives. 

We’re looking for passionate, mission-driven individuals to join us in creating a healthier and happier Texas.

Position Summary

Reporting to the Chief Clinical Officer, you will serve as the health plan's clinical point of contact for complex care coordination, care navigation, utilization management, and case management escalations. Working within a managed care environment that partners with delegated clinical vendors, you will act as a key liaison between the health plan, vendor clinical teams, and internal stakeholders to help resolve member care concerns and support a seamless healthcare experience.

As the first person to serve in this role, you will have a unique opportunity to help define and build the health plan's clinical escalation and care navigation function. You will leverage your clinical expertise and managed care knowledge to assess escalated situations, identify barriers to care, coordinate appropriate next steps, and facilitate resolution of complex or high-visibility member issues. You will collaborate closely with customer experience, sales, employer groups, brokers, provider relations, network, compliance, and operational teams to navigate challenges related to care management, provider access, transitions of care, and utilization management services, while helping establish best practices and processes for the future.

Success in this role requires strong clinical judgment, exceptional communication skills, and the ability to effectively coordinate across multiple stakeholders while maintaining a member-centered focus. The ideal candidate is an experienced RN who thrives in a collaborative environment, enjoys solving complex problems, and is excited by the opportunity to build, influence, and improve how the organization supports members with complex care needs.

Essential Job Functions

In this role, you will be responsible for:

Clinical Escalation Management

• Serve as a clinical resource and subject matter expert to internal stakeholders regarding managed care processes, care coordination workflows, utilization management practices, and member navigation challenges.
• Serve as the health plan's clinical point of contact for complex care coordination, care navigation, and member care escalations.
• Assess escalated cases to determine clinical context, urgency, barriers to care, and appropriate next steps.
• Manage urgent, complex or high-profile member issues involving utilization management, care management, provider access, transitions of care, benefits, and healthcare navigation.

Vendor Partnership & Care Coordination

• Partner with outsourced utilization management and case management vendors to facilitate timely resolution of escalated member concerns and ensure appropriate care coordination activities occur.
• Monitor vendor responsiveness, follow-through, and resolution outcomes, escalating concerns as appropriate to vendor leadership and internal stakeholders.
• Work with internal and external stakeholders to implement coordination of vendor processes and projects.
• Coordinate with internal departments including Customer Experience, Provider Relations, Compliance, Quality, Operations, and Medical Management to support effective issue resolution.

Clinical Risk Identification & Escalation

• Identify clinical, quality, access, compliance, privacy, grievance, or member safety concerns and ensure timely escalation to appropriate clinical or operational leaders.
• Recognize high-risk or urgent situations requiring involvement of vendor clinical teams, Medical Directors, Behavioral Health, Compliance, Quality, or executive leadership.