Job Details

Member Care Navigator

As the Member Care Navigator, you will provide members with exceptional support by delivering high quality, professional, and efficient service. You will also liaise with members and providers to assist in the coordination of care related to medical access complexities. 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 experiencefrom 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.

Member Advocacy & Support 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.

Provider Communication & Problem Solving 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.

Operational Excellence 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.

Clinical & Benefit Literacy Understand key clinical terms, service types, and the implications of delays in care. Confidently communicate around pre-authorization processes, diagnosis implications, and provider requirementswithout crossing clinical boundaries. Recognize scenarios requiring escalation due to potential impact on timelines or safety.