This role is responsible for the issuance of preauthorizations or precertifications based on medical necessity for complex cases.
The role is responsible of guiding patients and caregivers, helping them navigate through the health care system to ensure their healthcare needs are met.
The role must take ownership of the case and navigate the member, broker or assigned intermediary through the patient’s episode of care, managing members’ expectations following company guidelines.
The role is responsible for these functions for all Bupa Global members accessing care in the US through the BCBS agreement and in the case of Bupa Global Latinamerica members, also for the members accessing care through Olympus or any other US agreement.
- Assist patients and caregivers in navigating through appropriate services in the US.
- Facilitating communication between the patient, family members, and healthcare providers to ensure patient satisfaction and quality of care.
- Sends letter of authorization or denial and explanation of benefits based on policy conditions and or Non-Disclosure Review.
- Serves as a patient advocate, liaison, and adviser/educator to assist patients with navigating the continuum of care.
- Continuously reviews and evaluates patient progress as outlined within the plan of care. Communicates plan of care to patient and family and solicits concerns, questions, and issues for resolution.
- Serves as a liaison between patient and clinical staff, administration, physicians, and community/external resources to coordinate/maximize resources and identify/resolve barriers to the plan of care.
- Promotes patient health and comfort during their time in the US
- Educates and counsels patients on issues related to their health and life situations.
- Prevents complaints by counseling with supervisors and managers who see a problem developing; offering suggestions to resolve potential complaints; modifying practices that cause repeated complaints.
- Works conjointly with Case Managers / Clinicians or assigned teams at the corresponding regional offices for post-care out of the US
- Offers second medical opinion service following company guidelines
- Provides organized system of care to our members by assisting with In-network provider search, when requested
- Handles calls and emails from Business Partner’s, Brokers, Members and Service Centers when directed to them for care navigator role specific activities
- Enters notes for every conversation, email and decision in the system(s) so that it is available Companywide.
- Escalates cases to the US network provider, where applicable and owns the resolution of these, when interfering in the experience of care from the patient, member, broker, etc.
- Supports the call center staff in order to meet customer service Key Performance Indicators.
- Performs other related tasks as assigned.
The Ideal Candidate
- Bachelor’s degree in healthcare administration or Healthcare management preferred
- 8 years of clinical experience working in a hospital, managed care environment or medical office required.
- Case Management certification (or related) a plus
- Ability to identify resources and utilize problem solving skills in order to meet patient's individual needs
- Effective verbal and written communication skills
- Able to take and follow through with delegated tasks and accountability
- Ability to process and handle confidential information with discretion
- Ability to handle difficult and stressful situations with professional composure and empathy
- Excellent listening and interpersonal skills
- Bilingual (Spanish/English) required
- Excellent time management and organizational skills
- High understanding and proper handling of EMR
About the Company
Bupa Global is an Equal Opportunity Employer
Bupa is an equal opportunity employer and in compliance with the law prohibits discrimination against applicants and employees based on the following characteristics: veteran status, uniformed service member status, sex, race, color, ancestry, national origin, religion, age, marital status, sexual orientation, pregnancy, childbirth and related conditions, familial status, citizenship, sickle cell trait, AIDS/HIV status (actual or perceived), genetic information, testing or characteristics or any other legally recognized status entitled to protection under federal, state, and local anti-discrimination laws. Bupa’s Equal Employment Opportunity Policy applies to all applicants and employees with respect to all terms and conditions of employment, including recruitment, hiring, training, compensation, transfer, layoff recall, benefits, promotion and separation.