Shire Jobs

PRINCIPAL RESPONSIBILITIES:

Under general supervision from the Leadership of Long-Term Care (LTC), the LTC Health Navigator will support clinical staff of the Long-Term Care program. This role will focus on transitions of care and care coordination for members coming both in and out of Long-Term Care. The LTC Health Navigator will provide assistance in locating accepting facilities and to members needing support in accessing medical, social or behavioral services or information from providers and community services. The LTC Health Navigator will possess knowledge of current upcoming programs and services that intersect with LTC services, Enhanced Case Management, Community Support, Population Health Management, Regional Services, HCBS (Home and Community Based Services).

Principal responsibilities include:

• Prioritize, maintain, coordinate, process accurate and timely Long-Term Care admissions, and transitions throughout the continuum.
• Assist clinical staff in identifying members that may benefit from additional services.
• Establish, facilitate, and maintain effective ongoing relationships with network hospitals, SNFs, delegated groups, vendors and providers; facilitate communication and care coordination between networks entities.
• Provide guidance, support, education, coordination of care and other assistance to members and/or their family members, as needed.
• Provide predominately telephonic coordination and program support.
• Document care coordination and discharge planning needs, activities, and follow up actions in a timely manner according to Alliance policies and regulatory standards in the care management systems independently and in coordination with other team members.
• Participate in case conferences and meetings with nurses, social workers, and medical director(s) in order to support effective care coordination.
• Demonstrate a comprehensive understanding of coverage and benefits in order to promote appropriate service utilization and increase participant, member, and patient knowledge and satisfaction.
• Recognize and resolve continuity of care issues or other problem areas promptly.
• Identify and provide appropriate community referrals for members, facilitating access to appropriate support services, including medical and social resources to address presenting issues and assist in the removal of barriers.
• Collaborate in a positive interdisciplinary approach with other departments as well as community resources to ensure most appropriate level of care and optimal outcomes.
• Establish and leverage relationships with hospital discharge planners, LTC social workers, LTC IDT/ICT team members, LTC clinical team and community and social service agencies to ensure the needs of members are met and policies of the plan are followed.
• Demonstrate a comprehensive understanding of coverage and benefits to promote appropriate service utilization.
• Educate and answer inquiries from participants, patients, and members and/or their family members about benefits, services, eligibility, and referrals with a positive and professional approach.
• Complete other duties and special projects as assigned.

ESSENTIAL FUNCTIONS OF THE JOB

• Collaborate with Long-Term Care Providers, Skilled Nursing Facility staff, Hospitals, Delegated partners, and Internal businesses.
• Communicate with member, providers, and community organizations to ensure coordination of overall care services for members.
• Communicate effectively, both verbally and in written format.
• Prioritize and Multi-task.
• Meetings: Participate in departmental and non-departmental meetings and other scenarios.
• Perform writing, administration, data entry, analysis, and report preparation.
• Assist case managers in communicating and coordinating with PCPs, specialists, hospitals, and other providers on behalf of participants/patients/members.
• Comply with the organization Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

PHYSICAL REQUIREMENTS

• Constant and close visual work at desk or computer.
• Constant sitting and working at desk.
• Constant data entry using keyboard and mouse.
• Constant use of a telephone head-set.
• Frequent verbal and written communication with staff and other business associates by telephone or correspondence
• Frequent lifting of folders, files, binders and other objects weighing between 0 and 30 lbs.
• Frequent walking and standing.
• Occasional travel to hospitals and other facilities.
• Occasional driving of automobiles.

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

• Bachelor's degree or higher or equivalent professional work experience in health care related field

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• Three years healthcare or customer service experience in the healthcare field, preferably in a health plan setting and a working knowledge of medical and insurance terminology preferred.
• One year experience in care delivery or coordination in an outpatient clinic, office, home care or inpatient setting including care plan development, care coordination and discharge planning preferred.
• Knowledge of acute and chronic medical and behavioral health related topics desired

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Proficiency in correct English usage, grammar, and punctuation.
• Fluency in English required.
• Fluency in Vietnamese, Cantonese, Mandarin, Spanish or Tagalog a plus.
• Experience in managed care organization or health plan a plus.
• Knowledge of DMHC regulations and DHCS contractual requirements.
• Experience working with case managers a plus.
• Experience interacting with physicians, physician offices, hospital discharge coordinators, skilled nursing facilities, and/or community-based programs preferred.
• Experience in skilled or long-term care facility settings preferred.
• Good analytical and interpretive skills.
• Strong organizational skills, proactive and detail oriented.
• Sensitivity to a diverse, low-income community.
• Excellent critical thinking and problem-solving skills.
• Ability to act as resource.
• Excellent presentation, customer service and delivery skills.
• Familiarity with Alameda County resources a plus.
• Proficient experience in Windows including Microsoft Office suite.

SALARY RANGE 80,040.08 - $120,060.11 Annually

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.