Member Navigator

Summary of Position

• Provide support and assistance to mainstream Medicare, Medicaid, HARP, Child Health Plus and Essential members telephonically (inbound and outbound) with a variety of non‐clinical healthcare and membership needs: completing health care gaps, health related assessments, and state required applications to ensure continuous eligibility of healthcare coverage.
• Facilitate and aid Medicaid, HARP, CHP members as NYS Certified Application Counselor with state redetermination process including educating members on state qualifications, necessary proof of income and associated documents while completing required applications and submission to the state. 
• Proactively lead, facilitate, and assess member experience through targeted Medicare member outreach, including members with multiple complex issues, grievance and appeal cases as well as access to care challenges to continually improve healthcare performance and consumers assessment of EH ability to provide high quality services.  
• Navigate and provide direction and guidance during member interactions utilizing extensive knowledge of EmblemHealth’s products, complex processes, and multiple systems to enhance member’s health journey.  
• Responsible to grow/increase membership enrollments in value added services: Member Portal, Medicare Rewards, Auto Pay and Paperless through telephonic member interactions, etc.

Roles and Responsibilities

• Provide seamless care coordination and individual needs assessments from member onboarding and throughout member lifecycle to support Medicare, Medicaid, HARP, and CHP members with care/risk health gaps and health risk assessment.
• Provide member assistance with initial and annual health assessments.
• Identify members qualifying for Care Management programs and resources and collaborate through referrals to Care Management Team.
• Assist, coordinate and schedule members with primary care and specialty visits, tests and necessary screenings.   
• Intermediary and professional liaison with member and healthcare providers and provider facilities.
• Meet state mandated deadlines maintaining and acting with a sense of urgency.
• Facilitate and aid Medicaid, HARP, CHP members as NYS Certified Application Counselor with New York State of Health redetermination process including educating members on state qualifications, necessary proof of income and associated required documents while completing application and submission to the state.  
• Lead and facilitate complex application issues including mixed immigration status households, multi-tax household, family enrollment issues and complex income situations.
• Intermediary and professional liaison with the member and New York State of Health for coverage redeterminations including handling and submitting sensitive member information.  
• Proactively lead, facilitate, and assess member experience through targeted Medicare member outreach, including members with multiple complex issues, grievance and appeal cases as well as access to care challenges to continually improve healthcare performance and consumers assessment to provide high quality services.  
• Provide guidance, advice, and direction; and engage team members to solve for member issues.
• Collaborate and provide feedback to Director of Customer Retention and Loyalty team to understand member pain points and identify opportunities to mitigate.
• Onboard newly state assigned members and serve as guide for member plan and benefits. Set member expectations and enroll members in EH value added services including Member Portal, Member Rewards, Auto Pay while identifying member communications preferences including paperless.  
• Retain members targeted for termination of plan by New York State of Health. Assist and educate members on next steps, required paperwork; and institute temporary plan extensions for resolution.
• Retain members targeted for termination of plan due to lack of premium payment. Assist member in payment options and avoid loss of coverage.
• Support goals of the department by meeting quarterly with Customer Retention and Loyalty leadership team to review results and discuss ways to continually improve member satisfaction, loyalty, revenue (Quality and Risk Scores) and reduce costs.
• Participate in weekly meetings with manager and team members to discuss customer concerns, improvement opportunities (people, processes, and technology), and other company priorities.
• Assist, support, and conduct user acceptance testing as appropriate and outside of normal business hours.  
• Participate in state meetings as needed.
• Ongoing learning of EmblemHealth and Connecticare products and services, including any recent changes in business rules or decisions that may impact customer experience.
• Perform other duties assigned, directed, or required