Health Navigator

Description 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 Maintain adequate passing score on monthly productivity audits, including call volume and documentation volume Demonstrate availability to accept incoming calls during posted phone hours except when approved by leadership in advance Quality: Maintaining adequate passing score on monthly audits ESSENTIAL FUNCTIONS OF THE JOB Telephone: Complete and document all telephone calls to members and explain health plan program benefits to Alliance members. Describe the types of services the Alliance and other community partners offer. Computer: Accurately maintain member database to ensure data integrity. Meetings: Participate in departmental and non-departmental meetings and other scenarios. Perform writing, administration, data entry, analysis, and report preparation. Assist case managers in communicating and coordinating with PCPs , specialists, hospitals, and other providers on behalf of participants/patients/members. Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls. PHYSICAL REQUIREMENTS Constant and close visual work at desk or computer. Constant sitting and working at desk. Constant data entry using keyboard and mouse. Constant use of a telephone head-set. Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person. Frequent lifting of folders, files, binders and other objects weighing between 0 and 30 lbs. Frequent walking and standing. MINIMUM QUALIFICATIONS: EDUCATION OR TRAINING EQUIVALENT TO: Bachelor's degree or higher or equivalent professional work experience in health care related area of study preferred. Have a cleared TB test prior to or within seven days of hire. MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE: Three years healthcare or customer service experience in the healthcare field, preferably in a health plan setting and a working knowledge of medical and insurance terminology preferred. One year experience in care delivery or coordination in an outpatient clinic, office, home care or inpatient setting including care plan development, care coordination and discharge planning preferred. Knowledge of acute and chronic medical and behavioral health related topics desired SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE): Proficiency in correct English usage, grammar, and punctuation. Fluency in English required. Experience in managed care organization or health plan a plus. Experience working with case and disease managers or programs a plus. Experience interacting with physicians, physician offices, hospital discharge coordinators and/or community-based programs preferred. Good analytical and interpretive skills. Strong organizational skills, proactive and detail-oriented. Sensitivity to a diverse, low income community. Excellent critical thinking and problem solving skills. Ability to act as resource. Excellent presentation, customer service and delivery skills. Familiarity with Alameda County resources a plus. Proficient experience in Windows including Microsoft Office suite.
Employees who interact with members of the public may be required to be tested for Tuberculosis and fully vaccinated against COVID-19 and influenza. Successful candidates for those positions/ classifications may be required to submit proof of vaccination against influenza and/or COVID-19, a negative Tuberculosis test, or request an exemption for qualifying medical or religious reasons during the onboarding process. Candidates should not present proof of vaccination until instructed to do so by the Human Resources department.

SALARY RANGE $69,606.86-$104,410.30 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.