Member Care Navigator (On-Site or Remote)

The OccuNet Company•Fort Worth, TX

22h•Hybrid

About The Position

The OccuNet Company is an innovative healthcare cost‑containment organization committed to improving access to affordable, high‑quality healthcare. We pride ourselves on an outward‑mindset culture that values empathy, respect, and seeing one another as whole people. Our team thrives in a fast‑paced, growth‑oriented environment where continuous learning and collaboration drive our success. At OccuNet, you matter like we matter! Our team members share a positive attitude, an outward mindset, problem-solving abilities, and patience, enabling them to provide excellent customer service even during challenging situations. Our culture, plus continuous opportunities for growth, has resulted in an industry-low turnover rate. Don’t miss out on this rare opening with us!

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.

Nice To Haves

Bilingual (Spanish) preferred.

Responsibilities

Answer incoming calls and support members in scheduling appointments and accessing appropriate care.
Maintain open, continuous communication between members and providers.
Research accepting physicians or facilities based on plan design, member needs, and access barriers.
Partner closely 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 ensuring timely follow up, documentation, and clear next steps.
Make outbound calls to providers, clients, and partners to gather information, educate stakeholders, and provide updates.
Attend training and team meetings to stay current on workflows, tools, and plan updates.
Deliver a high‑empathy, member‑first experience in every interaction.
Acknowledge frustration, build trust, and help members confidently navigate their benefits.
Explain open‑network plans, reference‑based pricing, and member benefits in simple, jargon‑free language.
Own each case through resolution with proactive updates and follow‑through.
Document all interactions thoroughly and accurately to ensure continuity of care, compliance, and quality.
Liaise professionally with providers to clarify plan details, payment processes, and network structure.
Navigate provider pushback with calm, respectful communication.
Identify accepting or RBP‑friendly facilities and provide alternative options when needed.
Coordinate Single Case Agreements (SCAs) or escalations based on internal criteria.
Investigate delays or barriers that threaten timely care and act decisively to overcome them.
Follow established workflows, boundaries, and escalation protocols with precision.
Use internal research tools (OnPoint, PON, provider lookup systems) to verify provider options.
Prioritize inquiries based on urgency, member risk, and available details.
Collaborate across departments to establish processes that remove barriers to care.
Uphold compliance standards, including HIPAA and Department of Labor guidelines.
Maintain confidentiality of all sensitive information.
Understand key clinical terms, service types, and the implications of delays in care.
Confidently communicate around pre‑authorization processes, diagnosis implications, and provider requirements—without crossing clinical boundaries.
Recognize scenarios requiring escalation due to potential impact on timelines or safety.