Care Navigator

Job Description: The following broad responsibility statements are representative of the basic expectations about the role or function. Depending on business needs and exigencies, these responsibility statements may be modified. Critical to any leadership function is the need to demonstrate flexibility and agility in adapting to the changing requirements of the business. 1. Support members by collaborating with hospital ER staff to assess case urgency, ensuring that only qualified emergency cases, whether Outpatient or In-patient, are directed to the Emergency Room. This involves coordinating with healthcare professionals to prioritize critical cases, and allocating resources for timely and effective care. The focus on prioritizing emergency cases aims to optimize ER efficiency and improve patient outcomes. 2. Provide assistance to members during Emergency Room (ER) visits by efficient/ timely issuance of Letters of Authorization (LOA) to facilitate access to medical services. Implement redirection strategies as needed to direct non-emergency cases to alternative healthcare facilities or services. This includes offering guidance on available healthcare options, and ensuring smooth transitions to optimize the suitability and efficiency of care delivery. 3. Handle various concerns and inquiries related to Emergency Room (ER) availment and miscellaneous items. Provide assistance and clarification to members on ER services, eligibility, coverage, and procedures. By effectively addressing these concerns, ensure Information Classification: Protected Form Template Control: Talent Acquisition/August 12, 2025/FO-TA-0.007/Rev.00 members are well-informed and supported, contributing to a positive patient experience and optimal ER resource utilization. 4. Facilitate initial Letter of Authorization (LOA) for In-Patient Cases. Collaborate with healthcare professionals to assess patient needs, compile required documentation, and communicate relevant information. Ensure timely and appropriate care upon admission until discharge, promoting continuity of care and optimal patient outcomes. 5. Act as gatekeeper and screen for unnecessary charges in accordance with our memo. This involves carefully reviewing charges and expenses to ensure compliance with established guidelines and protocols. By diligently fulfilling this role, we aim to prevent unnecessary costs and uphold financial accountability within the organization. 6. Provide detailed explanations of benefits and review coverage and non-coverage based on their benefit provision. Additionally, offer direct assistance to members who are unaccompanied, addressing any questions or concerns they may have, ensuring they receive the necessary support and understanding. 7. Promotion and Steerage to our Primary Care Networks. Encourage and assist members in visiting our Primary Care Networks (PCNs), providing full support and guidance. This includes advocating for PCN benefits and helping members understand available services. 8. Enhance cost savings by directing non-emergency cases to more suitable healthcare services or facilities. This includes evaluating case urgency and guiding individuals towards alternative care options. Through this approach, we strive to maximize resource utilization, reduce unnecessary expenses, and promote overall efficiency and financial sustainability within the organization. 9. Execute various campaigns and tasks as needed during manpower shortages, business continuity planning (BCP) events, or when Service Level (SL) for other teams or sub-units are critically low, ensuring operations remain smooth and responsive to immediate demands. DESIRED SKILLS AND COMPETENCIES ● Effective Prioritization and Timely Decision Making: Ability to prioritize tasks efficiently and make timely decisions to address issues promptly. ● Assertive Negotiation and Influencing Skills: Capability to negotiate effectively and influence Maxicare business results positively. ● Empathetic and Concise Communication: Ability to communicate empathetically and skill in conveying information clearly and succinctly to ensure effective communication. ● Conflict Resolution and Interdisciplinary Collaboration: Proficiency in resolving conflicts and collaborating with interdisciplinary teams to achieve common goals. ● Efficient and Proactive Customer Service: Capacity to provide proactive and personalized customer service efficiently, demonstrating empathy and active listening. ● In-Depth Knowledge on Products, Policies, and Procedures: Thorough understanding of Maxicare products, policies, and procedures, with attention to detail and a willingness to share knowledge. ● Critical Thinking and Critical Decision-Making: Ability to think critically and make sound decisions based on thorough analysis and evaluation. ● Adaptability and Ethical Standards: Flexible in adjusting to changing circumstances while maintaining patient confidentiality and adhering to ethical practices. ● Proficient in using Google Applications (Gmail, GSheets & etc.). EDUCATIONAL REQUIREMENT Graduate of 4 years of any medical and allied courses. A Bachelor's degree in a Healthcare or Medical-related field is preferred. Alternatively, candidates with at least 3 years of college education with a minimum of 2 years experience in Customer Service, or work experience in the medical field. EXPERIENCE AND TRAINING ● Preferably with at least 3 years experience in a customer service role. ● Preferred industry orientation: Healthcare, Insurance, Pharmaceuticals, FMCG, or any service-oriented industry ● Preferably with basic knowledge of medicines, the pathophysiology of illnesses/diseases, and nursing intervention (if nurse).