Member Care Navigator (On-Site or Remote)

Member Care Navigator (On-Site or Remote)

The OccuNet Company is an innovative company striving to reduce the cost of healthcare. We are a passionate group of people that care about affordable access to healthcare without sacrificing experience. We strive to make healthcare more intelligent, streamlined, and cost-effective. We offer industry-leading capabilities on negotiations-driven levers to contain rising healthcare costs while taking an experience-centric approach improving the health and well-being of those we serve. We pride ourselves on our tight knit culture based on the 'outward mindset' philosophy, emphasizing empathy, mutual respect, and seeing each other as "whole people." We have an ambitious vision and are growing quickly. We are seeking team members who are excited about our growth, seeking to thrive in a fast-paced environment, and enthusiastic about developing their skills and career alongside us.

Job Title: Regional Director of Care Navigation

Job Summary: As the Regional Director of Care Navigation, 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.

About The OccuNet Company (TOC): The OccuNet Company is an innovative healthcare cost‑containment organization committed to improving access to affordable, high‑quality healthcare. We pride ourselves on an outward‑mindset culture that values empathy, respect, and seeing one another as whole people. Our team thrives in a fast‑paced, growth‑oriented environment where continuous learning and collaboration drive our success.

What it's Like to Work Here: At OccuNet, you matter like we matter! Our team members share a positive attitude, an outward mindset, problem-solving abilities, and patience, enabling them to provide excellent customer service even during challenging situations. Our culture, plus continuous opportunities for growth, has resulted in an industry-low turnover rate. Don't miss out on this rare opening with us!

A Day in the Life:

• 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 experience—from 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.

Duties & Responsibilities

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 requirements—without crossing clinical boundaries.
• Recognize scenarios requiring escalation due to potential impact on timelines or safety.

Required Skills & Qualifications

• High school diploma or equivalent required.
• Foundational understanding of medical cost containment products (RBP, out‑of‑network, access coordination).
• Knowledge of CPT codes, claims forms, or general medical insurance preferred.
• Experience in healthcare navigation, patient access, medical office operations, insurance verification, case management, or high‑emotion customer service environments strongly preferred.
• Exceptional verbal and written communication skills.
• Empathy, emotional resilience, and the ability to stay calm under pressure.
• Strong judgment and ability to navigate sensitive or ambiguous situations.
• Persistent, detail‑oriented, and committed to accurate documentation.
• Ability to manage multiple tasks simultaneously and adapt to frequent changes.
• Skilled in problem‑solving and anticipating member needs.
• Bilingual (Spanish) preferred.

Success Indicators

• A successful Care Navigator consistently demonstrates:
• High‑quality member experience characterized by trust, clarity, and empathy.
• Timely and accurate case documentation and workflow adherence.
• Ability to professionally overcome provider resistance.
• Strong cross‑functional collaboration.
• Sound judgment, composure, and reliability under pressure.
• Ownership and follow‑through on all assigned cases.

Working Environment

• Fast‑paced, member‑centric operations setting.
• Frequent balancing of urgent inquiries, provider calls, and detailed research.
• Highly collaborative environment with emphasis on communication, teamwork, and adaptability.
• Culture built around mindfulness, problem‑solving, and "outward mindset" principles.

Culture and Opportunities

• We pride ourselves on our outward mindset – supporting each other and putting the team and the clients we serve first
• High-growth environment with clear opportunities for career growth
• Welcoming atmosphere and culture

Benefits

• 401(k) with matching
• Dental insurance
• Health insurance
• Vision insurance
• Health savings account
• Paid time off