ALAMEDA ALLIANCE FOR HEALTH
Overview
Description
PRINCIPAL RESPONSIBILITIES:
Under general supervision from the Leadership of Case Management, the Health Navigator will support clinical staff through the completion of components of case management and disease management programs. The Health Navigator will maintain an ongoing caseload with support from clinical staff as needed. This role will focus on high and moderate risk care coordination, providing short and long-term assistance to members needing support in accessing medical, social, or behavioral services or information from providers and community services.
Principal responsibilities include:
- Assist clinical staff in identifying and providing outreach, orientation, and comprehensive assessment services to moderate and high-risk participants, members, and patients that may benefit from services.
- Establish and maintain effective, ongoing relationships by facilitating communication and coordination with participants, patients, and members, their caregivers and PCPs/Providers as well as other identified resources to which the patient was referred, based on each member's continued needs.
- Provide guidance, support, education, coordination of care, and other assistance to participants, members, and patients 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 participant, member, and patient knowledge and satisfaction.
- Recognize and resolve continuity of care issues or other problem areas promptly.
- Educate and answer inquiries from participants, patients, and members and/or their family members about benefits, services, eligibility, and referrals with a positive and professional approach, promoting participant, patient, and member satisfaction and retention.
- Demonstrate a patient-centered approach to self-management skills for chronic disease conditions 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 participants, patients, and 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 the most appropriate level of care and optimal outcomes.
- Assist with outreach and planning for monthly Learning Collaboratives.
- Process referrals and prior authorizations for ECM services.
- 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.
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 headset.
- 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 a health care related area of study preferred.
- Have a cleared TB test prior to or within seven days of hire.
- Current CPR and first aid card prior to or within six months of hire is preferred.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
- Three years of 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 of 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.
- Fluency in Vietnamese, Cantonese, Mandarin, Spanish, or Tagalog a plus.
- 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 a resource.
- Excellent presentation, customer service, and delivery skills.
- Familiarity with Alameda County resources a plus.
- Proficient experience in Windows including Microsoft Office suite.
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.
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