Job Information
Allameda Alliance for Health Health Navigator / Job Req 721743115 in Alameda, California
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 members 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 enrollm nt staff/vendors to assist in continuity in enrollment.
- Complete other duties and special projects as assigned.
- Productivity:
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``` - - 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
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``` - Quality:
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``` - - 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 organizations 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