Care Navigator (Temporary)

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.
• Screens 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
• License/Certifications: N/A
• Other: Satisfactory Criminal Offender Record Information (CORI) results and access to reliable transportation
• Experience: Minimum 2 years’ experience in managed care, medical, or community social service settings
• Understanding of hospitalization, discharge planning, and post-acute needs
• Knowledge of medical terminology, documentation, and disease processes
• Ability to recognize clinical triggers requiring RN involvement
• Experience with motivational interviewing and diverse/non-English-speaking populations
• Knowledge of social determinants of health
• Proficiency with Microsoft Office (Excel, Word, Outlook)