Five Star Member Navigator​/remote​/hybrid

At Prairie States, excellence is a shared goal. Over 100 professionals, working together, commit themselves daily to improving the health benefit experience of our members and their families.

We are always looking for talented, ambitious and dedicated people to join our team. If you’re interested in seeing your efforts recognized and appreciated, and in helping people in a meaningful way, please view our current career opportunities.

Position:Five Star Member Navigator (full-time / remote / hybrid)

Location: Sheboygan, WI

Job :161

# of Openings:1

FIVE STAR MEMBER NAVIGATOR (FULL-TIME / REMOTE / HYBRID)
This is a full-time position with a hybrid remote work arrangement in our Sheboygan, WI location. No weekends, holidays or on-call rotations. Ideal candidate will work in Wisconsin. Work Schedule Monday-Friday 8:30 AM - 4:30 PM - include a one hour paid lunch!
Prairie States Enterprises, Inc. is a third party administrator, a benefits industry leader, and a trusted advisor to self-insured companies and their employees. We provide a complete range of medical benefit management services, all performed in-house, and to exacting standards of excellence.

JOB SUMMARY

The role of the Five Star Member Navigator is to provide a clinically enhanced member experience beginning with the initial phone call through the completion of service or reason for the contact. Five Star Member Navigators function as part of a team from the customer service perspective. The Five Star Member Navigator will also navigate members to high value providers based on direct contracts and episodes of care within a network.

The Navigator is also responsible for internal referrals to other services at PSE, transfers to internal and external health plan related services as needed, and pro-active efforts with regard to promoting preventive screens and adherence to national guidelines for a variety of common chronic conditions. Five Star Member Navigators serve in both an ‘inbound’ and ‘outbound’ role with regard to member relations.

Extended service hours are part of the Five Star service model.

SUMMARY OF ESSENTIAL JOB FUNCTIONS

• Member navigation to high value providers based on member’s needs for services within the available direct contracts or bundles/episodes of care.
• Work collaboratively with Five Star Navigators and nurses on clinical member needs as assigned.
• Documentation of interactions and guidance provided to members.
• Work with customer clinics/DPCs on care navigation needs
• Work with contracting entities as needed
• Coordinate weekly meetings with vendor partners and internal Five Star and nursing teams to ensure collaboration on member needs.
• Create out of area student plan with regard to network access
• Coordinate with second opinion entities and programs as needed.
• Internal referrals to pre-cert, UM, CM, DM and Optimal Health as needed based on member needs.
• Coordinating care or services as needed
• Other duties as requested or assigned

• Education –LPN or ADN required with current licensure in good standing OR minimum of 2 years of care navigation experience
• Experience – 3 years in a clinical or hospital setting OR 2 years of care navigation
• Effective communication skills including oral, nonverbal and written
• Ability to work collaboratively with the Health Services team and other PSE departments
• Ability to manage an independent case load
• Strong organizational skills
• Strong sense of customer service
• Ability to work with diverse individuals
• Adherence to and application of HIPAA regulations
• Computer
  
  Skills:
  
  Word, Excel, Microsoft Outlook, keyboarding and data entry
• Experience in utilization review, concurrent review and/or discharge planning
• Must be able to carry on conversations with…