Plan Care Navigator

PruittHealth•McDonough, GA

About The Position

The plan care navigator serves as a point of contact and specialized care partner for members enrolled in PruittHealth Premier. This role focuses on problem solving, clinical care coordination, conducting structured phone assessments, monitoring health status, improving patient engagement, and assisting with closing gaps in care. The goal is to provide excellent customer service, proactive support, improve health outcomes, helping members access care and services, assist with benefit navigation, and help prevent unnecessary hospitalizations or emergency room visits.

Requirements

Understanding the referral and prior authorization process.
Understand the PruittHealth Premier Plan benefits, PruittHealth Premier Plan policies, procedures and articulate them effectively to providers, members and key decisions makers.
Knowledge of CMS regulations and Model of Care requirements.
Understanding of HIPAA compliance and medical data security
EMR, care management platform, Microsoft Office, and reporting proficiency.
Excellent communication and interpersonal skills.
Exceptional organizational abilities to handle a high volume of member calls
Ability to prioritize multiple assignments and manage complex clinical situations.
Strong analytical, organizational, and problem-solving ability.
Ability to work independently and collaboratively across disciplines.
Minimum 1–2 years of clinical experience in a medical office, telehealth, facility, or case management role.

Nice To Haves

Proven background working with older adults or geriatric populations is highly preferred.
Active Medical Assistant certification preferred (CMA, CCMA, or RMA)
LCSW preferred
Associate degree or coursework in health sciences, human services, or medical services, or Medical Assistant Accreditation or Bachelors of Social Work

Responsibilities

Handle inbound calls, assess member needs, and provide appropriate guidance.
Offer live phone support to answer questions and address concerns before appointments.
Proactively manage patient care workflows from initial outreach to case resolution.
Escalate items such as abnormal or elevated vital signs, medical history concerns, or other clinical concerns to RNs.
Accurately document all patient interactions using electronic health records (EHR) document all calls through platforms for call center; utilize phone call scripts
Conduct check-in calls with enrolled patients to review symptoms, medications, and general well-being.
Review individualized care plans with patients under the direct supervision of a licensed provider or supervisor.
Coordinate medical services between primary care physicians, specialists, labs, and ancillary healthcare providers.
Assist with routine tasks such as scheduling follow-up appointments, processing medication refills, and tracking referral statuses.
Assist with scheduling transportation
Supplemental benefit navigation
Assisting with receipt of durable medical equipment
Complete welcome calls and scheduling of health risk assessments
Hospital discharge follow- up
Interdisciplinary care team meeting support
Monitor patient health data and clear incoming vital sign readings via Remote Patient Monitoring (RPM) software.
Escalate clinical flags or urgent patient updates to supervising nurses or physicians according to clinic protocols.
Assisting the patient in achieving better health outcomes by addressing their questions and concerns and navigating them to the right resources including assisting with referrals to specialty care and community-based organizations.
Maintain complete data privacy across all digital touchpoints in absolute compliance with HIPAA regulations