Member Care Navigator (On-Site in Amarillo, TX)

The OccuNet Company•Amarillo, TX

1d•Onsite

About The Position

The Member Care Navigator provides high-quality, professional, and efficient support to members, helping them coordinate care and navigate medical access complexities. The role supports appointment scheduling, access to appropriate care, and communication between members and providers, while owning cases from intake through resolution. The navigator advocates for members, explains open-network plans, reference-based pricing, and benefits in clear language, researches suitable physicians and facilities, and addresses barriers to timely care. The role involves coordinating with providers and internal teams, documenting interactions, following established workflows and escalation protocols, and protecting confidential information. Navigators also attend training and team meetings to stay current on workflows, tools, and plan updates. This is a fast-paced, collaborative, member-centric operations setting requiring frequent prioritization of urgent inquiries, provider calls, and detailed research. The company describes its culture as growth-oriented and grounded in empathy, mutual respect, teamwork, and an “outward mindset.”

Requirements

High school diploma or equivalent.
Foundational understanding of medical cost-containment products, including reference-based pricing, out-of-network care, and access coordination.
Exceptional verbal and written communication skills.
Empathy, emotional resilience, and ability to remain calm under pressure.
Strong judgment and ability to navigate sensitive or ambiguous situations.
Persistence, attention to detail, and commitment to accurate documentation.
Ability to manage multiple tasks simultaneously and adapt to frequent changes.
Problem-solving skills and ability to anticipate member needs.

Nice To Haves

Knowledge of CPT codes, claims forms, or general medical insurance.
Experience in healthcare navigation, patient access, medical office operations, insurance verification, case management, or high-emotion customer service environments.
Bilingual Spanish.

Responsibilities

Answer incoming calls and help members schedule appointments and access appropriate care.
Maintain continuous communication between members and providers.
Research accepting physicians and facilities based on plan design, member needs, and access barriers.
Collaborate with Account Management, Contracting, Advocacy, Pre-Neg, and TPA teams to resolve access issues.
Manage each case from intake through resolution, including timely follow-up, documentation, and clear next steps.
Make outbound calls to providers, clients, and partners to gather information, educate stakeholders, and provide updates.
Deliver empathetic, member-first support; acknowledge frustration, build trust, and help members navigate their benefits.
Explain open-network plans, reference-based pricing, and member benefits in clear, jargon-free language.
Document interactions accurately and thoroughly to support continuity of care, compliance, and quality.
Communicate with providers to clarify plan details, payment processes, and network structure.
Address provider resistance respectfully and identify accepting or reference-based-pricing-friendly facilities and alternatives.
Coordinate Single Case Agreements or escalations according to internal criteria.
Investigate delays and access barriers that may threaten timely care and take action to address them.
Follow workflows, role boundaries, and escalation protocols; use internal tools such as OnPoint, PON, and provider lookup systems to verify provider options.
Prioritize inquiries according to urgency, member risk, and available information.
Collaborate across departments to establish processes that remove barriers to care.
Follow HIPAA and Department of Labor guidelines and maintain confidentiality of sensitive information.
Use clinical and benefit knowledge to communicate about pre-authorization, diagnosis implications, and provider requirements without crossing clinical boundaries.
Recognize situations requiring escalation because of possible impacts on care timelines or safety.
Attend training and team meetings to stay current on workflows, tools, and plan updates.