Referral And Claims Navigator

Public Health Management-posted 2 months ago
Philadelphia, PA
1,001-5,000 employees
Religious, Grantmaking, Civic, Professional, and Similar Organizations
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Health Promotion Council of Southeastern Pennsylvania, Inc. (HPC) has been providing chronic disease prevention and management services in the community since 1981. HPC's programs and services are delivered across key departments that address public health concerns such as nutrition quality and food access, asthma, arthritis, diabetes, pre-diabetes, nicotine and other addictions, cancer, hypertension, family and parenting health, and community violence through community-based outreach, education and advocacy. The Training and Capacity Building (TCAP) department of HPC seeks a motivated and detail-oriented candidate with a background or interest in the intersection of public health, community services and clinical care for the role of Referral and Claims Navigator. This position is responsible for ensuring the seamless navigation of referrals and ensuring clean claims and successful reimbursement of eligible programs and services are tracked and completed through to our subcontracted partners. Referral navigation services are performed through the Health Referral Hub and Community Care Hub to ensure completed referrals to community and clinical resources while also ensuring individuals are assessed for Social Determinants of Health (SDOH) or Health-Related Social Needs (HRSNs). This Coordinator reports to the Program Manager and is a critical part of the TCAP department team within HPC. The position is contingent upon available and ongoing funding from a variety of federal, state, and local private and public funding sources.

  • Monitor Health Referral Hub phone calls, respond to voicemails, emails and text messages and engage prospective participants in eligibility screening and program enrollment.
  • Make referrals to partner organizations utilizing PA Navigate, Vega or another referral platform.
  • Conduct Social Determinants of Health (SDOH) screening, assessment, and perform data entry and resource navigation for identified Health Related Social Needs (HRSN).
  • Complete insurance verification protocols as needed.
  • Track referrals and collect data on referral outcomes, successes and challenges. Adjust workflows to maximize referrals as necessary.
  • Conduct outreach to healthcare provider offices to increase referrals into the National Diabetes Prevention Program, and other evidence-based programs and services to address SDOHs for participating health plans, and Medicare/Medicare Advantage plans.
  • Conduct outreach to community-based and other clinical partners to establish and maintain trust, collaboration and increase referral opportunities.
  • Assist with the development of marketing and outreach resources for TCAP programs and services.
  • Liaise with other HPC and PHMC departments to increase referrals into TCAP programming.
  • Attend and represent HPC at community outreach events.
  • Participate in and initiate conversations that contribute to new approaches for the improvement of program delivery, content, and/or evaluation.
  • Participate in team meetings, staff meetings and regular supervision.
  • Ensure all job assignments are completed according to timeline and priority.
  • Perform other duties and responsibilities as assigned.
  • Support claims processing by supporting internal and external data collection and management procedures; complete insurance validation as necessary.
  • Submit claims using PC-ACE software or other claims software as needed.
  • Assist colleagues with claims reconciliation. Liaise with technology vendors as needed to clean claims.
  • Provide updates to department colleagues on denied claims, reasoning and potential solutions.
  • In partnership with department colleagues, develop Stand Operating Procedures and best practices associated with claims submission and reconciliation.
  • Effective verbal and written communication
  • Sufficient knowledge and capability with Microsoft Suite, specifically Word, Excel, PowerPoint, Teams and Outlook
  • Sufficient knowledge of insurance types and claims processing requirements; willingness to learn if gaps in knowledge
  • Sufficient knowledge of medical and insurance terminology, CPT, ICD coding structures and billing forms (i.e. CMS 1500). Willingness to learn if gaps in knowledge.
  • Strong organizational and time management skills, attention to detail, flexibility and ability to work independently and as part of a team
  • Willingness and ability to adapt to changing work demands and to understand and implement all policies and procedures of a complex, multi-service organization
  • Personal commitment to promoting and learning about healthy lifestyles
  • Ability to handle confidential information in accordance with company policies and procedures
  • Strong customer services skills and Comfortability in public engagement settings
  • Bilingual in Spanish and English is a plus, but not required
  • Willingness to obtain additional training and certifications, such as - claims and billing coding, Community Health Worker, Peer educator and facilitator
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