Social Health Member Navigator

Let’s do great things, together!

About Moda
Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.

Position Summary
This position provides support to the EOCCO Health Related Social Needs (HRSN) Operations team by assisting in the monitoring and review of Health-Related Social Needs coverage requests. In addition, this position completes referrals to case management, and HRSN service providers. This position fulfills the contractual obligation with the Oregon Health Authority (OHA) regarding collaboration between health plans and community partners in overseeing the utilization of services by all members, particularly those that make up the prioritized populations identified in various Oregon Administrative Rulings.   This is a FT hybrid position based in Portland, Oregon. 

Pay Range
$54,668.32 - $68,340.67 annually (depending on experience)
*Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.

Please fill out an application on our company page, linked below, to be considered for this position.

 

Benefits:

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

 

Required Skills, Experience & Education:

• Bachelor’s degree or equivalent.
• 2+ years of experience in healthcare, public health, community-based organizations, including work in or with rural or underserved communities.
• Experience in a medical office, social work, case management and/or utilization management preferred.
• Traditional Health Worker certification or intent to complete within 6 months of hire date.
• Proven history of strong attention to detail and thoroughness.
• Detailed understanding of HRSN and Medicaid complexities.
• Proven history of strong organizational skills and ability to meet established deadlines.
• Ability to work well under pressure in a complex and rapidly changing environment.
• Ability to communicate customers and members interests and needs to internal project teammates, to improve work flows and processes.
• Strong presentation skills.
• Type a minimum of 60 wpm net on a computer keyboard.
• Strong statistical, analytical, and problem-solving skills.
• Excellent oral, written, and interpersonal communication skills, and the ability to interact professionally, patiently, and courteously with customers over the phone, and in person.
• Ability to maintain confidentiality and present a positive and professional image in the communities we serve.
• Demonstrates proficiency in desktop application software including email, word processing, spreadsheets and creating presentations.

 

Primary Functions :

• Conducts eligibility screenings for HRSN requests which includes outreach to members, providers, or other entities.
• Determines the most effective utilization of HRSN funds by reviewing requests against state established criteria.
• Reviews requests from outside entities, triages member needs, and directs to care coordination.
• Manages HRSN requests to ensure members are offered and receive medically necessary services.  
• Ensures documentation in the HRSN needs assessment is thorough for all member-related service requests and meets Oregon Health Authority requirements.
• Provides education to members and providers regarding Health-Related Social Needs, including how to request, criteria for coverage, availability of resources, and case management services.
• Consult with the HRSN Manager or RN on complex cases.
• Utilizes multiple business accounts for ordering and tracking items approved through HRSN benefits.
• Remains current on all Oregon Health Authority guidance regarding health-related social needs benefits
• Utilizes the Moda Health core systems (CCA, Facets, benefit tracker, etc) for eligibility and benefit verification, documentation of contact with providers and members.
• Provides data entry for HRSN reporting
• Conducts post authorization referrals and assignments to HRSN service providers.  
• Provides additional outreach to members as needed to offer support services or connection to other resources.
• Completes documentation to support compliance deliverables related to reporting throughout the year.
• Send proper correspondence to providers, members, and other departments to identify support persons and notify EOCCO designated care coordination staff.
• Ensure adherence to the Health Insurance Portability and Accountability Act (HIPPA) and other regulatory guidelines including privacy and security.
• Must maintain 98% quality audit scores regarding care planning documentation.
• Identifies problems and researches alternative solutions.
• Works with other team members to meet member needs related to care coordination.
• Completes other duties and special projects as assigned
• Maintain accurate patient note entry in Moda systems to improve communication amongst internal and external partners.

Working Conditions & Contact with Others

• Hybrid office environment 3 days per week or more as needed with extensive close PC and keyboard work, consistent sitting must be able to navigate multiple screens. Work in excess of 40 hours per week, including evenings and occasional weekends, to meet business need.
• Multiple internal departments including, but not limited to: Healthcare Services, Case Management and Claims. Externally with Members, HRSN service providers, community-based organization and other health systems across service area.  

 

Together, we can be more. We can be better.

 
Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training. 

For more information regarding accommodations please direct your questions to Kristy Nehler and Daniel McGinnis via our View email address on j.brt.mv email.