This role is responsible for the issuance of preauthorization or precertification 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 Latin-American members, also for the members accessing care through GEM 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; includes also coordination with US Customer Service and Claims teams
- 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, web inquiries, fax 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 interaction, 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 to meet customer service Key Performance Indicators.
- Performs other related tasks as assigned.
- Flexible to peak seasons and months, with ability to attend to after-hour, weekends, and holiday necessities as related to the Navigator role. Also ability to attend shifts that are according to company policy, and that span from hours as indicated by the requirements of the role and team coverage.
The Ideal Candidate
- Bachelor’s degree in healthcare administration or Healthcare management preferred
- 8-10 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 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); Business communication (verbal and written) proficiency in English required
- Excellent time management and organizational skills
- High understanding and proper handling of EMR
** Please assure to add an updated copy of your Resume to your application. Applications or profiles without an updated Resume will not be considered. **
** Por favor, asegúrese de añadir una copia actualizada de su currículum a su solicitud. No se tendrán en cuenta las solicitudes o perfiles que no tengan un currículum actualizado. **