Manager of Member Navigators

 

 

COMMUNITY HEALTH PLAN



 

Manager of Member Navigators

 

 

KEY RELATIONSHIPS:

Reports to: Director of Care Management

 

Supervises: Direct reports include Member Navigators (for Medicare Advantage Special Needs Plan).

 

Other Key Relationships (Peer and/or Collaborative):  Medical Management Team, Med Ops Team, Customer Care, Provider Relations, Vice President and Chief Medical Officer, Providers and Clinic staff at PCP and Specialty Care Clinics, community agencies, Plan Medicare Program staff, Plan State Program Manager.

 

FLSA: Exempt

 

 

POSITION PURPOSE:

This position assures alignment of the Member Navigator program with organizational strategic direction, goals, measures and initiatives. The Manager of Member Navigators is responsible for program development, as well as recruiting, training, and management of regional Member Navigator staff.

The primary purpose of the Member Navigator program is to serve Community Health Plan Medicare Advantage Special Needs Plan (SNP) beneficiaries by coordinating services related to their health, community and entitlement program needs.

 

PRINCIPLE DUTIES:

A. Responsible for development and implementation of the Member Navigator program.

B. Responsible for ensuring the day-to-day operations of the program, including identification of staffing and resource needs, effective hiring, appropriate performance management, staff development, with the goal of developing an empowered, knowledgeable and productive decentralized work team.

C. Responsible for the development and management of a program with a non-traditional structure: to include, but not limited to, assessment of Member Center ability to integrate with/supplement Plan efforts or to provide Navigator functions at the Clinic level; determination of resource needs at Plan and Clinic levels; development and administration of comprehensive Member Center certification program.

D. Develops program standards and measures to assure that contractual, federal and state requirements are met.

E.  Facilitates the development, revision and approval of policies and procedures.

F.  Performs continuous evaluation of program effectiveness and implements improvements as needed.

G. Develops a program management plan that includes periodic site visits as well as routine and regular contact with field staff.

H. Assures Member Navigator activities are documented appropriately and that the documentation is readily available to Plan staff, as needed.

I.  Works to assure Member Navigator findings are used for appropriate referral to Care Management staff and outcome tracking.

J. Develops a thorough understanding of healthcare and service needs of the Medicare population, with particular focus on SNP beneficiaries.

K.  Facilitates the development and maintenance of regional reference materials.

L.  Facilitates on-going education and updates regarding Federal and State entitlement programs for Member Navigators.

M. Develops and maintains excellent relationship with Primary Care Providers and their clinic staff, regional CMS office and HRSA program staff.

N.  Actively participates in the development of other special needs / Care Management programs as needed.

O.  Other duties as assigned.

 

QUALIFICATIONS:

Education and Training: 

Master of Social Work, Master of Public Health, Bachelor of Science in Nursing or other related field preferred.

Prior Related Experience: 

?  Three years of supervisory experience required.

?  3+ years of experience working directly with clients/patients in social services, human services or health care fields.

?  Experience in care delivery within the ambulatory / primary care setting.

?  Experience in accessing and assisting individuals, utilizing multiple community agencies.

?  Experience in program development and management

?  Experience with federal and state entitlement programs.

Knowledge, Skills and Abilities:

?  Thorough knowledge of federal and state entitlement programs and systems.

?  Ability to work with individuals with multiple psychosocial and health issues.

?  Ability to work collaboratively with providers, multiple community agencies and systems.

?  Ability to work effectively with, communicate to, and support various levels of management.

?  Demonstrated ability to effectively supervise and lead staff, including the ability to achieve results through influencing people.

?  Excellent communication skills, both verbal and written.

?  Strong organizational skills and ability to handle multiple priorities.

?  Strong analytical skills and ability to make decisions.

?  Strong project management skills and ability to oversee development and implementation of multiple initiatives including the ability to implement new programs and products and the ability to translate strategy into action.

?  Ability to develop and manage high-level plans and strategies, while maintaining awareness/comfort with detail.

?  Computer skills ?Windows, Microsoft Office Programs (Word, Excel, Powerpoint and Access) preferred.

?  Ability to travel.

?  Ability to maintain a professional demeanor and confidentiality.

?  Sensitivity to the needs of every individual to be treated with respect and fairness.Other

Eligible to participate in local, state and federal health care programs including Medicare and Medicaid.

 

PHYSICAL REQUIREMENTS

Requires sitting, standing or walking while reviewing documents or working with staff.  Requires speaking by phone with providers, purchasers or other Plan staff.  Requires vision and hearing to normal range.  Requires working throughout the facility, carrying out assignments unassisted.  Requires travel via public transportation, automobile or plane.  Regular and punctual attendance is a condition of employment.Access to Protected Health Information

Individual performing the principle duties of Manager of Member Navigators  must have access to, and protect the confidentiality of, the following minimum necessary information in order to assist staff with beneficiary interaction, to oversee employee performance, and for data review and analysis:

?  Member demographic information (name, address, phone number, gender, date of birth, social security number, etc.);

?  Correspondence and other communications from and to a member, provider or representative acting on behalf of the member;

?  Current and previous coverage information;

?  Previous contact information with member, provider, and/or representative acting on behalf of the member (telephone records, correspondence, etc.);

?  Referrals, prior authorizations, hospital notifications, case management notes, claims payment information;

?  Encounter history, pertinent medical and specialist information, member home care support and social support information, etc.;

?  Correspondence related to and results from external reviews by independent review organizations.

 

The above is intended to describe the general content of and the requirements for satisfactory performance of this position.  It is not to be construed as an exhaustive statement of the duties, responsibilities of this position.