Health Navigator

PRINCIPAL RESPONSIBILITIES :

Under general supervision from the Non-Clinical Supervisor, Case Management, the Health Navigator will support members in case management and disease management programs. The Health Navigator will maintain an on-going caseload with support from clinical staff as needed. This role will focus on care coordination, providing short- and long-term assistance to members needing support in accessing medically covered and not covered services, including but not limited to medical, social, behavioral, and / or community services.

Principal responsibilities include :

• Identify, outreach, and assess members that may benefit from services.
• Establish and maintain effective, ongoing relationships by facilitating communication and coordination with members, PCPs / Providers, caregivers, and others involved in member's care.
• identify resources to which the member may be referred, based on each member's continued needs.
• Provide guidance, support, education, coordination of care and other assistance to members and / or their family members, as they move through the healthcare continuum.
• Provide telephonic, email, or face-to-face support to participants, patients, and members in the case and disease management programs to meet their treatment / care plan goals in coordination with case managers where appropriate.
• Document care coordination and discharge planning needs, activities, and follow up actions in a timely manner according to Alliance policies and regulatory standards in the care management systems independently and in coordination with case managers and other team members.
• Participate in case conferences and meetings with case managers and medical director(s) in order to support effective care coordination.
• Demonstrate a comprehensive understanding of coverage and benefits in order to promote appropriate service utilization and increase member knowledge and satisfaction.
• Recognize and resolve continuity of care issues or other problem areas promptly.
• Educate and answer inquiries from members and / or their family members about benefits, services, eligibility and referrals with a positive and professional approach, promoting member satisfaction and retention.
• Demonstrate a patient-centered approach to self-management skills and provide decision support, urgent care support, symptom management support, basic health and wellness information, and educational resources.
• The navigator will work with Enhanced Care Management (ECM) members enrolled in ECM with the external ECM Providers per Department of Health Care Services guidelines.
• Identify and provide appropriate community referrals for members, facilitating access to appropriate support services, including medical and social resources to address presenting issues and assist in the removal of barriers.
• Assist members in getting appointments and access to appropriate health care and community program services. Initiate follow-up to confirm and coordinate additional needs of the member to support coordination of care across care settings and needs.
• Collaborate in a positive interdisciplinary approach with other Case Managers and CM / DM staff, Medical Services, Provider Services, Member Services departments as well as community resources to ensure most appropriate level of care and optimal outcomes.
• Know, understand and comply with internal policies and procedures to ensure compliance with DHCS, DMHC and NCQA standards.
• Know when to escalate cases to a higher level of clinical support as appropriate (internal to RN or to ECM team).
• Maintain knowledge base of desk level procedures and stay up to date with training materials to meet regular productivity and quality departmental standards.
• Understand, know, comply with expectations for each case type : care coordination, complex, transitions of care etc.
• If appropriate, work with state and federal eligibility and enrollment staff / vendors to assist in continuity in enrollment.
• Complete other duties and special projects as assigned.
• Productivity :

Maintain caseload based on departmental needs

Maintaining adequate passing score on monthly audits

ESSENTIAL FUNCTIONS OF THE JOB

PHYSICAL REQUIREMENTS

MINIMUM QUALIFICATIONS :

EDUCATION OR TRAINING EQUIVALENT TO :

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE :

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE) :

SALARY RANGE $72,384.00-$108,596.80 ANNUALLY

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M / F / Vets / Disabled.

Salary : $72,384 - $108,597