Five Star Member Navigator (full-time / remote / hybrid)

Job Description

Job Description

FIVE STAR MEMBER NAVIGATOR (FULL-TIME / REMOTE / HYBRID) 

For interested candidates, click "Apply for this Position" here: & gni=8a7887a8a0abfc8001a0ce92c5be6d05

This is a full-time position with a hybrid remote work arrangement in our Sheboygan, WI location.  No weekends, holidays or on-call rotations. Ideal candidate will work in Wisconsin.  Work Schedule Monday-Friday 8:30 AM - 4:30 PM - include a one hour paid lunch! 

Prairie States Enterprises, Inc. is a third party administrator, a benefits industry leader, and a trusted advisor to self-insured companies and their employees.  We provide a complete range of medical benefit management services, all performed in-house, and to exacting standards of excellence. 

 

JOB SUMMARY

 

The role of the FiveStar Member Navigator is to provide a clinically enhanced member experience beginning with the initial phone call through the completion of service or reason for the contact. FiveStar Member Navigators function as part of a team from the customer service perspective.  The FiveStar Member Navigator will also navigate members to high value providers based on direct contracts and episodes of care within a network.  The Navigator is also responsible for internal referrals to other services at PSE, transfers to internal and external health plan related services as needed, and pro-active efforts with regard to promoting preventive screens and adherence to national guidelines for a variety of common chronic conditions.  FiveStar Member Navigators serve in both an ‘inbound’ and ‘outbound’ role with regard to member relations.  

 

Extended service hours are part of the Five Star service model.

 

SUMMARY OF ESSENTIAL JOB FUNCTIONS

• Member navigation to high value providers based on member’s needs for services within the available direct contracts or bundles/episodes of care. 
• Work collaboratively with FiveStar Navigators and nurses on clinical member needs as assigned.
• Documentation of interactions and guidance provided to members.
• Work with customer clinics/DPCs on care navigation needs
• Work with contracting entities as needed
• Coordinate weekly meetings with vendor partners and internal FiveStar and nursing teams to ensure collaboration on member needs.
• Create out of area student plan with regard to network access
• Coordinate with second opinion entities and programs as needed.
• Provide member education
• Internal referrals to pre-cert, UM, CM, DM and Optimal Health as needed based on member needs.
• Coordinating care or services as needed
• Other duties as requested or assigned

 

POSITION REQUIREMENTS

• Education –LPN or ADN required with current licensure in good standing OR minimum of 2 years of care navigation experience
• Experience – 3 years in a clinical or hospital setting OR 2 years of care navigation
• Effective communication skills including oral, nonverbal and written
• Ability to work collaboratively with the Health Services team and other PSE departments
• Ability to manage an independent case load
• Strong organizational skills
• Strong sense of customer service
• Ability to work with diverse individuals
• Adherence to and application of HIPAA regulations
• Computer Skills: Word, Excel, Microsoft Outlook, keyboarding and data entry
• Experience in utilization review, concurrent review and /or discharge planning
• Telephone etiquette
• Must be able to carry on conversations with medical providers, and members to facilitate good understanding by all parties

 

REQUIRED COMPETENCIES

• Change Management – Accepts, supports, and executes assignments in conditions of change which support attaining department goals.
• Effective Communication – Demonstrates effective and responsive communications following the appropriate reporting structure.
• Accountability/Results – Achieves and/or exceeds result based goals that were specific, measurable, and timely.
• Teamwork – Demonstrates teamwork behaviors and makes positive contributions and which support the achievement of department goals.
• Customer Satisfaction – Dedicated to the PSE service model and meets or exceeds PSE customer satisfaction expectations in providing exemplary service.
• Professional Growth – Takes ownership of one’s professional growth within one’s current position and to advancement at PSE.

PHYSICAL DEMANDS / WORK ENVIRONMENT
This is sedentary position which requires the individual to sit for long periods of time and the proper positioning/posturing for extensive viewing of computer screens and computer related work is required.  It is encouraged that individuals intermix this sedentary time with periodic movement within one’s office space and/or to other office areas to counteract the sedentary nature of this position.  

To the selected candidate, we offer:  
Competitive compensation based on experience and a comprehensive benefit package provided to include Medical, Dental, Vision, Life, STD/LTD, FSA, Paid Time Off, personal days, 401k with match, wellness and exercise membership and more.  Checkout to view our full-time benefits flyer here:

 

Opportunity for meaningful career growth within a results-driven company and our company culture is one of ambition, integrity, empowerment, teamwork and a passion for personal and company success.

If this sounds like you and you’re seeking career growth with an exciting new career path in overseeing the quality of health care for our clients and their members, please send your cover letter and resume following the instructions for this site.  

Prairie States Enterprises
Equal Opportunity Employer \nCompany Description

About Us
Data-driven, customizable health plan administration backed by a unique clinical approach and quality customer service.

Experienced – Compassionate – Proven
At Prairie States, our top priority is creating and implementing innovative health benefits services that meet each customer’s specific needs and challenges head-on.

Since 1989, we have stood apart from other TPAs by doing things differently, and better. Registered nurses, who comprise over 30 percent of our staff, work side by side with our experienced claims processors. Backed by powerful data tools, they perform first-rate administration services with industry-leading accuracy informed by clinical expertise.

We’ve made our reputation on our high-touch, compassionate approach, and we’ve done it while helping employers significantly lower their costs.

Company Description

About Us\nData-driven, customizable health plan administration backed by a unique clinical approach and quality customer service.\n\nExperienced – Compassionate – Proven\nAt Prairie States, our top priority is creating and implementing innovative health benefits services that meet each customer’s specific needs and challenges head-on.\n\nSince 1989, we have stood apart from other TPAs by doing things differently, and better. Registered nurses, who comprise over 30 percent of our staff, work side by side with our experienced claims processors. Backed by powerful data tools, they perform first-rate administration services with industry-leading accuracy informed by clinical expertise.\n\nWe’ve made our reputation on our high-touch, compassionate approach, and we’ve done it while helping employers significantly lower their costs.\n