Member Care Navigator
Posted 1hrs ago
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Job Description
Member Care Navigator helping members schedule care, resolve provider barriers, and understand benefits. Supporting affordable healthcare access for The OccuNet Company’s cost-containment operations.
Responsibilities:
- Answer incoming calls and support members in scheduling appointments and accessing appropriate care.
- Maintain continuous communication between members and providers.
- Research accepting physicians or facilities based on plan design, member needs, and access barriers.
- Partner with Account Management, Contracting, Advocacy, Pre-Neg, and TPA teams to resolve access issues.
- Own the end-to-end member experience from intake through resolution, including timely follow-up, documentation, and clear next steps.
- Make outbound calls to providers, clients, and partners to gather information, educate stakeholders, and provide updates.
- Deliver a high-empathy, member-first experience and help members navigate benefits.
- Explain open-network plans, reference-based pricing, and member benefits in simple language.
- Liaise with providers regarding plan details, payment processes, and network structure.
- Identify accepting or RBP-friendly facilities and provide alternatives.
- Coordinate Single Case Agreements or escalations according to internal criteria.
- Investigate and overcome delays or barriers threatening timely care.
- Follow workflows, boundaries, and escalation protocols.
- Use OnPoint, PON, and provider lookup systems to verify provider options.
- Prioritize inquiries based on urgency, member risk, and available details.
- Collaborate across departments to establish barrier-removing processes.
- Attend training and team meetings to stay current on workflows, tools, and plan updates.
Requirements:
- High school diploma or equivalent required.
- Foundational understanding of medical cost containment products (RBP, out-of-network, access coordination).
- Knowledge of CPT codes, claims forms, or general medical insurance preferred.
- Experience in healthcare navigation, patient access, medical office operations, insurance verification, case management, or high-emotion customer service environments strongly preferred.
- Exceptional verbal and written communication skills.
- Empathy, emotional resilience, and the ability to stay calm under pressure.
- Strong judgment and ability to navigate sensitive or ambiguous situations.
- Persistent, detail-oriented, and committed to accurate documentation.
- Ability to manage multiple tasks simultaneously and adapt to frequent changes.
- Skilled in problem-solving and anticipating member needs.
- Bilingual (Spanish) preferred.
- Ability to uphold HIPAA and Department of Labor compliance standards.
- Ability to maintain confidentiality of sensitive information.
- Understanding of key clinical terms, service types, pre-authorization processes, diagnosis implications, and provider requirements without crossing clinical boundaries.
Benefits:
- 401(k) with matching
- Dental insurance
- Health insurance
- Vision insurance
- Health savings account
- Paid time off
- High-growth environment with clear opportunities for career growth
- Welcoming atmosphere and culture
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