Social Health Member Navigator

About the role

This position provides support to the EOCCO Health Related Social Needs (HRSN) Operations team by assisting in the monitoring and review of Health-Related Social Needs coverage requests. In addition, this position completes referrals to case management, and HRSN service providers. This position fulfills the contractual obligation with the Oregon Health Authority (OHA) regarding collaboration between health plans and community partners in overseeing the utilization of services by all members, particularly those that make up the prioritized populations identified in various Oregon Administrative Rulings.

Responsibilities

• Conducts eligibility screenings for HRSN requests which includes outreach to members, providers, or other entities.
• Determines the most effective utilization of HRSN funds by reviewing requests against state established criteria.
• Reviews requests from outside entities, triages member needs, and directs to care coordination.
• Manages HRSN requests to ensure members are offered and receive medically necessary services.
• Ensures documentation in the HRSN needs assessment is thorough for all member-related service requests and meets Oregon Health Authority requirements.
• Provides education to members and providers regarding Health-Related Social Needs, including how to request, criteria for coverage, availability of resources, and case management services.
• Consults with the HRSN Manager or RN on complex cases.
• Utilizes multiple business accounts for ordering and tracking items approved through HRSN benefits.
• Remains current on all Oregon Health Authority guidance regarding health-related social needs benefits.
• Utilizes the Moda Health core systems (CCA, Facets, benefit tracker, etc) for eligibility and benefit verification, documentation of contact with providers and members.
• Provides data entry for HRSN reporting.
• Conducts post authorization referrals and assignments to HRSN service providers.
• Provides additional outreach to members as needed to offer support services or connection to other resources.
• Completes documentation to support compliance deliverables related to reporting throughout the year.
• Sends proper correspondence to providers, members, and other departments to identify support persons and notify EOCCO designated care coordination staff.
• Ensures adherence to the Health Insurance Portability and Accountability Act (HIPPA) and other regulatory guidelines including privacy and security.
• Maintains 98% quality audit scores regarding care planning documentation.
• Identifies problems and researches alternative solutions.
• Works with other team members to meet member needs related to care coordination.
• Completes other duties and special projects as assigned.
• Maintain accurate patient note entry in Moda systems to improve communication amongst internal and external partners.

Requirements

• Bachelor’s degree or equivalent.
• 2+ years of experience in healthcare, public health, community-based organizations, including work in or with rural or underserved communities.
• Experience in a medical office, social work, case management and/or utilization management preferred.
• Traditional Health Worker certification or intent to complete within 6 months of hire date.
• Proven history of strong attention to detail and thoroughness.
• Detailed understanding of HRSN and Medicaid complexities.
• Proven history of strong organizational skills and ability to meet established deadlines.
• Ability to work well under pressure in a complex and rapidly changing environment.
• Ability to communicate customers and members interests and needs to internal project teammates, to improve work flows and processes.
• Strong presentation skills.
• Type a minimum of 60 wpm net on a computer keyboard.
• Strong statistical, analytical, and problem-solving skills.
• Excellent oral, written, and interpersonal communication skills, and the ability to interact professionally, patiently, and courteously with customers over the phone, and in person.
• Ability to maintain confidentiality and present a positive and professional image in the communities we serve.
• Demonstrates proficiency in desktop application software including email, word processing, spreadsheets and creating presentations.

Qualifications

None specified.

Skills

• Bilingual (Spanish/English)

Benefits

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