Care Navigator (East)

Responsibilities

• Conduct phone and, as appropriate, in-person assessments, screenings, and visits using TruCare; update individualized care plans and aim for first-contact resolution in a culturally responsive manner.
• Carefully coordinate and follow up on care needs, including post-transition outreach, appointment scheduling, medication support, and service monitoring.
• Educate members/representatives on benefits, coverage criteria, rights, appeals, authorizations, and evidence of coverage.
• Identify and address gaps in care (e.g., PCP assignment, preventive screenings, vaccinations) per established protocols.
• Screen for social determinants of health and refer to community resources (e.g., food, housing, fuel assistance, transportation); escalate clinical decisions to the Nurse Case Manager or PCP.
• Advocate for members’ access to covered benefits and coordinate with community agencies for non-covered supports.
• Participate in—and as appropriate, lead—care plan meetings with providers, partners, and care team members.
• Collaborate with the interdisciplinary team (e.g., LTC, behavioral health, advanced practitioners, community partners) to support coordinated care.
• Build effective working relationships with community partners and providers (e.g., housing, ADH, assisted living, LTC facilities, PCPs) to support timely, member-specific communication.
• Submit and track requests/authorizations for covered services; ensure accuracy and timeliness per program workflows.
• Educate members and providers on authorization processes and help resolve authorization issues.
• Facilitate access to medical, behavioral health, and social services, including arranging transportation when needed.
• Communicate timely updates with members, caregivers, providers, and internal teams on care plans, service changes, and member status.
• Partner with LTC and community teams during admissions, transitions, and discharges to ensure continuity of care.
• Complete required activities to meet CMS/State, NCQA, HEDIS, and other standards (e.g., welcome calls, screenings, care plans).
• Document accurately and on time in TruCare and related systems; review and validate member panel data and reports.

Qualifications

• Education: College degree (BA/BS in Health Services or Social Work) preferred.
• Licenses/Certifications: N/A.
• Other: Satisfactory Criminal Offender Record Information (CORI) results, driving your personal motor vehicle is an essential job function.
• Experience: 2+ years’ experience in managed care and/or community-based health and human services (e.g., home health, personal care management, independent living, ASAP, or relevant state agencies) preferred; understanding of hospitalization and post-discharge needs required; working knowledge of medical terminology, common conditions, and medical record documentation; ability to identify triggers requiring RN intervention required; motivational interviewing experience and ability to work effectively with diverse and non-English-speaking populations required; understanding of social determinants of health required; proficiency with Microsoft Office (Excel, Outlook, Word) required; experience with face-to-face member visits and working with providers/community partners preferred; experience working on a multidisciplinary care team within a managed care organization preferred.