Health Navigator I

About the role

Provides phone, email and chat-based customer service to members of certain Performance Guarantee (PG) and Moda 360 groups by analyzing caller’s needs and providing timely and accurate responses. Answers inquiries from policyholders, members, agents, providers, hospitals, pharmacists, dentists and others regarding a wide variety of issues and questions related to a member’s benefits and health program options. This position requires staff to be flexible with their work schedule to meet the client’s needs. This is FT WFH role.

Responsibilities

• Handles medical, dental and/or pharmacy inquiries or a combination of two of these, depending on existing skills and training. Opportunity for promotion to Health Navigator II upon learning all three lines of business.
• Answers medical, dental and/or pharmacy claim, authorization and benefit questions from customers on specific groups. Provides solutions to problems, confirms eligibility and explains benefits and plan coverage.
• Handles inquiries received via phone, email, voicemail and/or online chat.
• Responds to members via phone, online chat, SMS and email.
• Completes detailed research and follow-up as needed. May include use of multiple resources, contact with internal departments and multiple phone calls to providers, pharmacies and other carriers to resolve a situation completely.
• Works with internal departments via email, phone or meetings to resolve member issues and ensure clear communication of the member’s needs.
• Analyzes situations and communicates effectively in a fast-paced environment that includes working with frustrated or angry callers.
• Uses the Moda 360 Navigator Console to review recommended health actions and programs, recommend programs based on personalized member data and assist members in understanding and setting up programs or completing recommended health actions.
• Uses multiple resources simultaneously to research member issues. These could include Facets, Benefit Tracker, Content Manager, eviCore portal, Navitus, CoverMyMeds, Moda 360 Navigator Console and other internal and external websites depending on the line(s) of business.
• Provides complete and accurate information in a professional manner both verbally and in writing.
• Talks on the phone or responds via chat while simultaneously researching the caller’s questions and documenting the interaction.
• Applies mathematical skills to determine correct benefit and claim information and manually calculates and updates dental incentive levels when needed.
• Exercises judgment, initiative, and discretion with confidential and sensitive subject matter.
• Provides thorough resolution when at all possible for members by using critical thinking skills, extending yourself and reducing effort on the part of the caller. This could include reaching out to internal and external sources (including service providers) to assist in resolving the issue for the member and making multiple follow-up calls to the member until the issue is resolved.
• Performs related duties:
• Reviews, updates and becomes familiar with new and revised benefit information.
• Builds and maintains proficiency in claim processing procedures to determine whether a claim was processed or adjusted correctly. Communicates reasoning to callers in language appropriate to the caller’s experience level.
• Requests claim adjustments required due to processing or configuration errors or new information and determines which incorrect processing is the result of a configuration error versus a processing error. When a configuration error is encountered, communicates with leadership to have it corrected.
• Identifies confusing or incomplete information in all internal and external resources, plans documents and member communications and makes suggestions for improvements.
• Updates and enters primary care physician selections based on plan benefits (medical only).
• Completes provider searches that may include calling several providers to locate providers who are in-network, available and meet the member’s care needs.
• Works with internal departments to help resolve member gaps in care when possible, including work with the Healthcare Services or Pharmacy teams on exceptions and authorizations for those trained in medical or pharmacy, respectively.
• Advocates on behalf of members when they encounter issues with obtaining covered care or medications from providers and/or pharmacies.
• Plays overrides to allow pharmacies to dispense medication at the point of service when appropriate based on plan details and internal policies (pharmacy only).
• Addresses and explains complaints, appeals, and grievances.
• Provides customer service to walk-in members.
• Sends emails or text messages to members to follow up on call details or provide forms, website links or other plan documents.
• Sends faxes to providers to allow them to submit medication authorization requests (pharmacy only).
• Provides timely follow up and return calls when these are required.
• Answers calls within PG service level agreement.
• Completes continuing education on excellent customer service skills.
• Performs other related duties and projects as assigned by lead, supervisor or manager.

Requirements

• A high school diploma or equivalent.
• Ability to complete training as a Customer Service Representative with Moda Health.
• Claim processing experience, prior customer service experience or other related experience such as medical/dental office or pharmacy preferred.
• Practical knowledge of medical, dental and/or pharmacy terminology desired.
• Knowledge of diagnosis and procedure coding helpful.
• Excellent oral and written communication skills. Ability to interact professionally, patiently, and courteously with customers over the phone and in writing.
• Excellent analytical, problem-solving and decision-making skills.
• 10-key proficiency of 105 kpm net on a computer numeric keypad.
• Type a minimum of 25 wpm net on computer keyboard.
• Ability to work well under pressure in a complex and rapidly changing environment.
• Ability to maintain excellent attendance and punctuality.
• Maintain confidentiality and project a professional business presence.
• Ability to work with multiple applications across multiple monitors at once and learn new applications as needed.
• Experience using Microsoft Office products including Outlook, OneNote and Teams.
• Experience with TriZetto Facets helpful.
• Ability to learn independently and take initiative to constantly improve skills.

Qualifications

• Though open to both internal and external candidates, internal candidates must be Fully Meeting performance expectations in their current position. Exceeding in Accuracy and Customer Service Skills is preferred.
• Complete Effortless Experience training and certification after hire.

Skills

• Bilingual (Spanish/English)

Benefits

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays