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 public