Care Coordinator (Navigator) - Must be fluent in Mandarin - Looking for a new career?

  • Fallon Community Health Plan
  • Worcester, Massachusetts
  • Mar 22, 2019
Medical

Job Description

Brief Summary Of Purpose:

The NaviCare Navigator purpose is to:
  • Perform tasks and actions to ensure all CMS and State member related regulatory mandates are met including but not limited to welcome calls, care plans, health risk assessments for the 'Community Well' member population, and member service plans according to Program Policy and Process
  • Manage a member panel in conjunction with other employed NaviCare Clinical Team members (members other than those in the State assigned 'Community Well' Program) in a culturally sensitive way
  • Manage members in the 'Community Well' Program with the contracted Aging Service Access Point Geriatric Support Service Coordinator and contracted primary care provider - this includes conducting face to face or telephonic health risk assessments in a culturally sensitive way, completing care plans, and reviewing claims and other data which may indicate a need for Nurse Case Manager involvement and assessment
  • Educate and assist members and/or personal authorized representatives (PRAs) on matters associated with NaviCare insurance coverage and benefits performing a member advocacy and education role including but not limited to member rights
  • Establish positive relationships with members/caregivers, community providers, and others involved in member care
  • Proactively intervene and work to help retain members on the plan when dissatisfaction or other issues may result in a member voluntarily leaving the plan
  • Be the central communicator and care coordinator to all members of the interdisciplinary care team and keep care team members abreast on member status during their membership in the plan and also at time of care transition to ensure care team members know of the member care transition so they are able to proactively participate in member discharge planning need
  • Educate members on their unique care plan and obtains their approval
  • Educate members on preventative screenings and other health care procedures such as vaccines, screenings according to established protocols and program process
  • Generate requests and authorizations for Medicaid covered services per the member care plan ensuring all services requiring authorization have accurate and timely authorizations in place in the Fallon Health system with accuracy and timeliness per program process
  • Educate providers, contracted vendors, Aging Service Access Point staff, and others about the NaviCare Program and benefits
  • Provide care coordination consistent with member specific care plan, ensuring the services that are on the care plan are implemented
  • Obtain medical records and other required documents from the health care providers and ensures uploading into the Central Enrollee Record
  • May be embedded in provider offices/sites/facilities at all times representing NaviCare in a positive collaborative manner
  • May lead member case review with providers and other members of the care team

Responsibilities:

Member Education, Advocacy, and Care Coordination
  • Conducts in home visits to members with member's consent in a culturally sensitive way. Visits may be by self, or with others on the Care Team
  • Monitors the daily in patient census and notifies all members of the care team when members have a care transition and 'where' they are for discharge planning and communication purposes
  • Follows up with members following transition of care to ensure member attended follow up appointments, if they have any questions etc. and ensure all members of the Care Team are knowledgeable about the care transition and work collaboratively to ensure the member care plan meets needs
  • Provides culturally appropriate care coordination i.e.: arranges for interpreters, provides communication documents in appropriate language, demonstrates culturally appropriate behavior when working with member/family
  • Develops and fosters relationships with members and providers/facilities to be the first point of contact for NaviCare insurance and benefit related questions and is able to explain processes including but not limited to: coverage criteria, appeal rights and processes, authorization request process, formulary, and evidence of coverage details
  • Performs home visits with members, responds promptly to member calls/questions and follows up per department processes at all times demonstrating exceptional customer service skills
  • Manages a member panel in conjunction with other employed NaviCare Clinical Team members (members other than those in the State assigned 'Community Well' Program) in a culturally sensitive way
  • Manages members in the 'Community Well' Program with the contracted Aging Service Access Point Geriatric Support Service Coordinator and contracted primary care provider - this includes conducting face to face or telephonic health risk assessments in a culturally sensitive way, completing care plans, and reviewing claims and other data which may indicate a need for Nurse Case Manager involvement and assessment
  • Serves as an advocate for members to ensure they receive NaviCare benefits as appropriate and if member needs are identified but not covered by NaviCare, works with community agencies to facilitate access to programs such as community transportation, food programs, and other services available through senior centers and other community programs


Provider Partnerships and Collaboration
  • Attends and contributes to scheduled and ad hoc provider Model of Care trainings/orientations with providers explaining Navigator role and NaviCare benefits
  • Attends in person care plan meetings with providers and office staff and leads care plan review with providers and care team
  • Partners with interdepartmental teams within Fallon Health to ensure provider educational needs are met and provider/member satisfaction is maintained, working to resolve issues expressed