Navigator - RN (Westbank Market Care Team)

US-LA-Peoples Health- Westbank
Job ID
3477
Category
Clinical - All

Overview

Position Purpose

The Navigator is responsible for ensuring a plan member's encounter with providers, office staff and Peoples Health is seamless and comprehensive. The Navigator will review, plan and coordinate health care services in order to utilize appropriate processes and appropriate resources to improve members’ health outcomes.

 

Scope of Position

The Navigator will use clinical and organizational knowledge to perform on-going assessment, problem identification, education and follow-up in order to coordinate care which results in improved health outcomes for members. The Navigator utilizes the market resources such as Care Coordinator-SW, Care Coordinator-RN, Nurse Practitioner and Pharmacist in the coordination of care for the member. The Navigator is the principal liaison for the member in their primary care patient centered medical home.

Responsibilities

Principal Responsibilities                                              

  1. Promotes a professional, positive image of Peoples Health
  2. Understands Peoples Health plans and assists members with appropriate utilization of their benefit and provides answers to questions presented.
  3. Educates Members on the patient centered medical home model
  4. Engages Members in the management of their health and well-being to make optimal use of their encounters
  5. Facilitates appointments with the PCP and specialists
  6. Conducts pre-visit planning by reviewing data in Member Viewer and PCP’s EMR, prior to scheduled appointment with PCP. Identifies HEDIS/STAR measures needed, current/past medication record, and current services being provided; creating a fact pack for the provider.
  7. Identifies services needed.
  8. Communicates and documents services needed and requested and follows appropriate protocol to obtain.
  9. Assists members with scheduling appointments for testing, treatments, follow-up, office procedures, etc. and assists in obtaining authorization and/or providing appropriate documentation for referral/appointment.
  10. Ensures results of testing, treatments, office procedures, etc. are received, reviewed and documented in member record accurately and in a timely manner. Communicates results appropriately.
  11. Works with providers and team members to coordinate member care and provides appropriate documentation needed to provider and/or team to ensure continuity of care.
  12. Identifies, documents, and communicates concerns or problems affecting members to appropriate departments. Actively follows-up on concern or problem until resolved and communicates resolution to member, if needed
  13. Coordinates services requiring authorizations and ensures appropriate documentation is submitted
  14. Documents and utilizes appropriate referrals to coordinate needed resources for member – pharmacy, DME, Social Services, Home Health, Chronic Care Improvement, etc. Submits appropriate documentation to support referral.
  15. Reviews and ensures documentation of member encounter is appropriate to satisfy HEDIS/STAR measures, medication measures, referrals, authorizations. Resolves issues if needed.
  16. Coordinates with team members post hospital discharge visits within seven days, performs med reconciliation and alerts provider to any issues or discrepancies with meds. Interfaces with members, providers and Peoples Health staff in coordinating member needs by providing appropriate documentation for referrals, services, etc. Ensures referrals, services, etc. are received and provides each member with a business card for future coordination and communication.
  17. Documents in CCMS any pertinent information discussed or done with members to ensure communication across PH departments in order to prevent duplicate efforts.
  18. Reviews Crystal reports at least monthly for HEDIS/STAR measures with Navigator Manager and additionally shares with office manager and providers in order to coordinate an action plan for improved measure performance and outcomes for members.
  19. Reviews performance with Navigator Manager monthly to ensure goals are being met.

Core Competencies

  • Professionalism
  • Strong verbal and written communication skills
  • Planning and organizational skills
  • Creative/innovative thinking
  • Negotiator
  • Conflict management and resolution
  • Manages time appropriately/efficiently/effectively
  • Strategic thinker

  • Problem solving and decision making

  • Effective listener

  • Collaboration and team work

  • Excellence with interpersonal relations

  • Ability to work independently and proactively, and make decisions.

  • Ability to handle multiple demands of diverse workload and prioritizes critical issues.

  • Ability to effectively interact with multifaceted medical professional staff.

  • Pleasant and helpful attitude

 

 

Qualifications

Experience/Education

 

  • Diploma or degree in nursing
  • BSN preferred
  • Minimum 3 years clinical experience in a patient care environment in clinical or similar setting required
  • Experience in managed care industry preferred
  • Understanding of HMO and third party administration preferred
  • Understanding of Nursing Home and Long Term Acute Care regulations preferred
  • Continuing education in the healthcare/managed care industry preferred
  • Knowledgeable and experienced in computer skills

License/Certification

  • Current Louisiana RN license required.
  • Valid driver’s license issued by the Department of Motor Vehicles required.

Physical Demands/Working Conditions

  • Must be able to lift 10-15 pounds and operate standard office equipment; computer, printer, fax, copier
  • Ability to travel between various PCP offices, hospitals, member’s residence and the Peoples Health corporate/field offices on a routine basis.
  • Must be available to work extended hours, overtime and non-traditional hours as needed.


Options

Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.
Share on your newsfeed