Five Star Member Navigator (full-time / remote / hybrid)

Prairieontheweb; Sheboygan (WI); Hybrid; USD 60,000 - 76,000; Full time

Benefits offered by this job

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

401k with match

Paid Time Off

Job summary

Prairie States Enterprises, Inc. seeks a Five Star Member Navigator to deliver a clinically enhanced member experience from first call to service completion.

The role involves guiding members to high value providers, coordinating internal referrals, and promoting preventive care in collaboration with nurses and FiveStar navigators. The position is full-time with a hybrid remote work arrangement in Sheboygan, WI, with a Monday–Friday schedule and no weekends.

Qualifications

• Education – LPN or ADN with current licensure in good standing, OR minimum of 2 years of care navigation experience.
• Experience – 3 years in a clinical or hospital setting OR 2 years of care navigation.
• Strong communication skills (oral, nonverbal, written).
• Ability to work collaboratively with Health Services team and other PSE departments.
• Ability to manage an independent caseload.
• Strong organizational skills and customer service mindset.
• HIPAA regulations adherence.
• Proficiency in Word, Excel, and Outlook.

Responsibilities

• Member navigation to high value providers based on needs within contracts or bundles.
• Collaborate with nurses on clinical member needs.
• Document interactions and guidance provided to members.
• Coordinate with clinics/DPCs on care navigation needs.
• Interact with contracting entities as needed.
• Plan and coordinate vendor partner meetings for member needs.
• Provide internal referrals to pre-cert, UM, CM, DM and Optimal Health.
• Coordinate with second opinion programs as needed.
• Support care coordination and other duties as assigned.

Skills

Effective communication

Collaboration with health services

Independent caseload management

Organizational skills

Customer service orientation

HIPAA adherence

Proficient in Word/Excel/Outlook

Education

LPN or ADN with current licensure in good standing

2+ years care navigation experience

Tools

Microsoft Outlook

Word

Excel

Job description

Grow Your Career Where Passion Meets Purpose

At Prairie States, excellence is a shared goal. Over 100 professionals, working together, commit themselves daily to improving the health benefit experience of our members and their families.

We are always looking for talented, ambitious and dedicated people to join our team. If you’re interested in seeing your efforts recognized and appreciated, and in helping people in a meaningful way, please view our current career opportunities.

Position:Five Star Member Navigator (full-time / remote / hybrid)

Location: Sheboygan, WI

Job Id:161

# of Openings:1

FIVE STAR MEMBER NAVIGATOR (FULL-TIME / REMOTE / HYBRID)
This is a full-time position with a hybrid remote work arrangement in our Sheboygan, WI location. No weekends, holidays or on-call rotations. Ideal candidate will work in Wisconsin. Work Schedule Monday-Friday 8:30 AM - 4:30 PM - include a one hour paid lunch!
Prairie States Enterprises, Inc. is a third party administrator, a benefits industry leader, and a trusted advisor to self-insured companies and their employees. We provide a complete range of medical benefit management services, all performed in-house, and to exacting standards of excellence.

JOB SUMMARY

The role of the FiveStar Member Navigator is to provide a clinically enhanced member experience beginning with the initial phone call through the completion of service or reason for the contact. FiveStar Member Navigators function as part of a team from the customer service perspective. The FiveStar Member Navigator will also navigate members to high value providers based on direct contracts and episodes of care within a network. The Navigator is also responsible for internal referrals to other services at PSE, transfers to internal and external health plan related services as needed, and pro-active efforts with regard to promoting preventive screens and adherence to national guidelines for a variety of common chronic conditions. FiveStar Member Navigators serve in both an ‘inbound’ and ‘outbound’ role with regard to member relations.

Extended service hours are part of the Five Star service model.

SUMMARY OF ESSENTIAL JOB FUNCTIONS

• Member navigation to high value providers based on member’s needs for services within the available direct contracts or bundles/episodes of care.
• Work collaboratively with FiveStar Navigators and nurses on clinical member needs as assigned.
• Documentation of interactions and guidance provided to members.
• Work with customer clinics/DPCs on care navigation needs
• Work with contracting entities as needed
• Coordinate weekly meetings with vendor partners and internal FiveStar and nursing teams to ensure collaboration on member needs.
• Create out of area student plan with regard to network access
• Coordinate with second opinion entities and programs as needed.
• Internal referrals to pre-cert, UM, CM, DM and Optimal Health as needed based on member needs.
• Coordinating care or services as needed
• Other duties as requested or assigned

POSITION REQUIREMENTS

• Education –LPN or ADN required with current licensure in good standing OR minimum of 2 years of care navigation experience
• Experience – 3 years in a clinical or hospital setting OR 2 years of care navigation
• Effective communication skills including oral, nonverbal and written
• Ability to work collaboratively with the Health Services team and other PSE departments
• Ability to manage an independent case load
• Strong organizational skills
• Strong sense of customer service
• Ability to work with diverse individuals
• Adherence to and application of HIPAA regulations
• Computer Skills: Word, Excel, Microsoft Outlook, keyboarding and data entry
• Experience in utilization review, concurrent review and/or discharge planning
• Must be able to carry on conversations with medical providers, and members to facilitate good understanding by all parties

FIVE STAR MEMBER NAVIGATOR (FULL-TIME / REMOTE / HYBRID)
This is a full-time position with a hybrid remote work arrangement in our Sheboygan, WI location. No weekends, holidays or on-call rotations. Ideal candidate will work in Wisconsin. Work Schedule Monday-Friday 8:30 AM - 4:30 PM - include a one hour paid lunch!
Prairie States Enterprises, Inc. is a third party administrator, a benefits industry leader, and a trusted advisor to self-insured companies and their employees. We provide a complete range of medical benefit management services, all performed in-house, and to exacting standards of excellence.
JOB SUMMARY The role of the FiveStar Member Navigator is to provide a clinically enhanced member experience beginning with the initial phone call through the completion of service or reason for the contact. FiveStar Member Navigators function as part of a team from the customer service perspective. The FiveStar Member Navigator will also navigate members to high value providers based on direct contracts and episodes of care within a network. The Navigator is also responsible for internal referrals to other services at PSE, transfers to internal and external health plan related services as needed, and pro-active efforts with regard to promoting preventive screens and adherence to national guidelines for a variety of common chronic conditions. FiveStar Member Navigators serve in both an ‘inbound’ and ‘outbound’ role with regard to member relations. Extended service hours are part of the Five Star service model. SUMMARY OF ESSENTIAL JOB FUNCTIONS

• Member navigation to high value providers based on member’s needs for services within the available direct contracts or bundles/episodes of care.
• Work collaboratively with FiveStar Navigators and nurses on clinical member needs as assigned.
• Documentation of interactions and guidance provided to members.
• Work with customer clinics/DPCs on care navigation needs
• Work with contracting entities as needed
• Coordinate weekly meetings with vendor partners and internal FiveStar and nursing teams to ensure collaboration on member needs.
• Create out of area student plan with regard to network access
• Coordinate with second opinion entities and programs as needed.
• Provide member education
• Internal referrals to pre-cert, UM, CM, DM and Optimal Health as needed based on member needs.
• Coordinating care or services as needed
• Other duties as requested or assigned

POSITION REQUIREMENTS

• Education –LPN or ADN required with current licensure in good standing OR minimum of 2 years of care navigation experience
• Experience – 3 years in a clinical or hospital setting OR 2 years of care navigation
• Effective communication skills including oral, nonverbal and written
• Ability to work collaboratively with the Health Services team and other PSE departments
• Ability to manage an independent case load
• Strong organizational skills
• Strong sense of customer service
• Ability to work with diverse individuals
• Adherence to and application of HIPAA regulations
• Computer Skills: Word, Excel, Microsoft Outlook, keyboarding and data entry
• Experience in utilization review, concurrent review and/or discharge planning
• Telephone etiquette
• Must be able to carry on conversations with medical providers, and members to facilitate good understanding by all parties

REQUIRED COMPETENCIES

• Change Management – Accepts, supports, and executes assignments in conditions of change which support attaining department goals.
• Effective Communication – Demonstrates effective and responsive communications following the appropriate reporting structure.
• Accountability/Results – Achieves and/or exceeds result based goals that were specific, measurable, and timely.
• Teamwork – Demonstrates teamwork behaviors and makes positive contributions and which support the achievement of department goals.
• Customer Satisfaction – Dedicated to the PSE service model and meets or exceeds PSE customer satisfaction expectations in providing exemplary service.
• Professional Growth – Takes ownership of one’s professional growth within one’s current position and to advancement at PSE.

PHYSICAL DEMANDS / WORK ENVIRONMENT
This is sedentary position which requires the individual to sit for long periods of time and the proper positioning/posturing for extensive viewing of computer screens and computer related work is required. It is encouraged that individuals intermix this sedentary time with periodic movement within one’s office space and/or to other office areas to counteract the sedentary nature of this position.
To the selected candidate, we offer:
Competitive compensation based on experience and a comprehensive benefit package provided to include Medical, Dental, Vision, Life, STD/LTD, FSA, Paid Time Off, personal days, 401k with match, wellness and exercise membership and more.

Opportunity for meaningful career growth within a results-driven company and our company culture is one of ambition, integrity, empowerment, teamwork and a passion for personal and company success.

Opportunity for meaningful career growth within a results-driven company and our company culture is one of ambition, integrity, empowerment, teamwork and a passion for personal and company success.

Prairie States Enterprises
Equal Opportunity Employer

We proudly offer competitive salaries, an engaging work environment, and opportunities for advancement. Plus, our comprehensive benefits package and robust employee wellness program support the health and happiness of our employees.

1 Hour PaidLunch

Wellness Reimbursement

Health, Dental, Vision and LifeInsurance.