Care Navigator

Care Navigator

The primary role of the Care Navigator is to assess and assist actively enrolled low-risk and unengaged QUEST members with understanding their health care benefits and accessing providers and services. A Care Navigator's time is spent telephonically reaching out to members to ensure they have access to care from in-network providers, community resource providers and plan benefits under the direction and in collaboration with the Interdisciplinary Care Team.

Primary Duties and Responsibilities:

• Perform initial outreach to complete welcome calls for newly enrolled QUEST members.
• Schedule and complete required initial and as needed telephonic health risk assessments.
• Provide telephonic support for inbound routine and complex calls received from members and providers via a call center queue.
• Provide member education and assisting with referral coordination and prior authorizations per member needs and eligibility.
• Document in an electronic care management system all assessment information and care management activities.
• Review prior assessments and historical claims to identify any signs of health status changes to assess member's level of care and/or prior to completing new assessment.
• Conduct Care Plan or Health Action Plan reviews with members as required to monitor and document the Member's progress of goals and services in their Care Plan or Health Action Plan.
• Assist with completion of eligibility forms required for Long Term Services and Supports (LTSS) services.
• Coordinate, collaborate, and participate with the interdisciplinary care team members including providers, family members, caregivers and community agencies to support members in maintaining or improving their current health status.
• Coordinate and collaborate with the appropriate internal departments as required per member's needs (e.g., Medical Management, Transition of Care, Disease Management, Care Coordination, Health Coordination, Travel, etc.) and in-network physicians/providers and community resource providers to facilitate timely access to available and approved services.
• Connect members with Social Determinates of Health (SDoH) needs to Community Resources in their neighborhood or area or utilizing the Unite Us tool.
• Perform member outreach calls for care management related to QUEST member's routine health screenings and outcome that may include data collection for HEDIS, STAR measures, and other member health plan events.
• Assisting the member with accessing translation services when needed and requested.
• Coordination of daily administrative responsibilities of documents copying, mailings, and faxes.
• Generating daily if not weekly Excel reports for daily work assignments and prioritize assigned duties.
• Meet operational and compliance with due dates for assessments, care plans, and all regulatory required activities.
• Perform tasks that align with and support departmental and organizational objectives
• Performing other duties as assigned by supervisor and/or manager per departmental needs.
• All other duties assigned.
• Adhere to regulatory compliance and quality guidelines as well as Aloha Care policies and procedures.
• Responsible for maintaining Aloha Care's confidential information in accordance with Aloha Care policies, and state and federal laws, rules and regulations regarding confidentiality. Employees have access to Aloha Care data based on the data classification assigned to this job title.

Requirements:

• High school diploma or equivalent.
• Minimum of 2 years of work experience in a customer service role, call center environment, and/or with customer facing responsibilities.
• Ability to establish rapport/relationships with members via a telephonic interview which includes gathering information about their medical history and/or socio-economic needs
• Ability to establish rapport with a multi-cultural - diversified population and experience with cultural sensitivity
• Achieves results, builds trust, communicate effectively, customer and quality focused.
• Strong interpersonal and facilitation skills with the ability to communicate with all levels of the organization.
• Strong, effective, and precise written and oral communication skills; speak clearly and persuasively in positive or negative situations.
• Professional telephonic etiquette skills.
• Ability to solve problems, analyze, think critically and make good judgment.
• Strong customer service skills and be able to work in a diverse, demanding and evolving environment with strong conflict and problem resolution skills.
• Able to work independently with minimal supervision.
• Able to effectively work in a fast-paced and changing environment, manage multiple projects and priorities across multiple teams/projects and in a matrixed environment.
• Possesses excellent time management and organizational skills; is dependable, enthusiastic, self-starting, and self-motivated. Uses time effectively, reacts professionally under pressure.
• Data entry experience with a high degree of accuracy and attention to detail.
• Intermediate skills…