Plan Care Navigator

Pruitthealth Corporation; Athens (GA); On-site; USD 48,000 - 60,000; Full time

Job summary

PruittHealth Corporation in Georgia seeks a Plan Care Navigator to coordinate care for members in the Premier program and perform structured phone assessments. You will monitor health status, document in EHR, and help close gaps in care to improve outcomes.

The role requires strong communication, organizational skills, and the ability to manage referrals, scheduling, and patient education while adhering to HIPAA and clinic protocols.

Qualifications

• Understanding of referral and prior authorization processes.
• Knowledge of PruittHealth Premier Plan policies and procedures.
• Familiarity with CMS regulations and Model of Care requirements.
• HIPAA compliance and medical data security awareness.
• Proficiency with EMR, care management platforms, Microsoft Office, and reporting.
• Excellent communication and interpersonal abilities.
• Strong organizational skills to handle high call volumes.
• Ability to prioritize multiple assignments in clinical settings.
• Analytical, problem-solving, and collaborative capabilities.

Responsibilities

• Handle inbound calls, assess member needs, and provide guidance.
• Provide live phone support to answer questions before appointments.
• Coordinate care workflows from outreach to case resolution.
• Escalate clinical concerns to RNs per protocol.
• Document interactions in EHR; utilize call-center scripts.
• Conduct check-in calls to review symptoms and medications.
• Review care plans with patients under supervision of a provider.
• Coordinate services between PCPs, specialists, labs, and other providers.
• Assist with scheduling, refills, and tracking referrals.
• Assist with scheduling transportation and durable medical equipment pickup
• Complete welcome calls and health risk assessments
• Support interdisciplinary team meetings
• Monitor health data and clarify RPM readings
• Escalate urgent updates to supervising staff as needed
• Guide patients to resources and referrals to specialty care
• Maintain HIPAA-compliant data privacy across digital touchpoints

Skills

Referral & prior authorization

PruittHealth Premier Plan knowledge

CMS regulations

HIPAA compliance

EMR & care management tools

Microsoft Office & reporting

Communication skills

Organizational skills

Multitasking & prioritization

Analytical & problem-solving

Education

High School diploma or GED

Associate degree or health sciences / CMA or related coursework

Tools

EMR system

Care management platform

Job description

Job Description - Plan Care Navigator (2612012)

Plan Care Navigator - 2612012

Description

JOB PURPOSE:

The plan care navigator serves as a point of contact and specialized care partner for members enrolled in PruittHealth Premier. This role focuses on problem solving, clinical care coordination, conducting structured phone assessments, monitoring health status, improving patient engagement, and assisting with closing gaps in care. The goal is to provide excellent customer service, proactive support, improve health outcomes, helping members access care and services, assist with benefit navigation, and help prevent unnecessary hospitalizations or emergency room visits.

KEY RESPONSIBILITIES:

1.Handle inbound calls, assess member needs, and provide appropriate guidance.

2.Offer live phone support to answer questions and address concerns before appointments.

3.Proactively manage patient care workflows from initial outreach to case resolution.

4.Escalate items such as abnormal or elevated vital signs, medical history concerns, or other clinical concerns to RNs.

5.Accurately document all patient interactions using electronic health records (EHR) document all calls through platforms for call center; utilize phone call scripts

6.Conduct check-in calls with enrolled patients to review symptoms, medications, and general well-being.

7.Review individualized care plans with patients under the direct supervision of a licensed provider or supervisor.

8.Coordinate medical services between primary care physicians, specialists, labs, and ancillary healthcare providers.

9.Assist with routine tasks such as scheduling follow-up appointments, processing medication refills, and tracking referral statuses.

10.Assist with scheduling transportation

12.Assisting with receipt of durable medical equipment

13.Complete welcome calls and scheduling of health risk assessments

15.Interdisciplinary care team meeting support

16.Monitor patient health data and clear incoming vital sign readings via Remote Patient Monitoring (RPM) software.

17.Escalate clinical flags or urgent patient updates to supervising nurses or physicians according to clinic protocols.

18.Assisting the patient in achieving better health outcomes by addressing their questions and concerns and navigating them to the right resources including assisting with referrals to specialty care and community-based organizations.

19.Maintain complete data privacy across all digital touchpoints in absolute compliance with HIPAA regulations

KNOWLEDGE, SKILLS, ABILITIES:

1.Understanding the referral and prior authorization process.

2.Understands the PruittHealth Premier Plan benefits, PruittHealth Premier Plan policies, procedures and articulate them effectively to providers, members and key decisions makers.

3.Knowledge of CMS regulations and Model of Care requirements.

4.Understanding of HIPAA compliance and medical data security

5.EMR, care management platform, Microsoft Office, and reporting proficiency.

6.Excellent communication and interpersonal skills.

7.Exceptional organizational abilities to handle a high volume of member calls

8.Ability to prioritize multiple assignments and manage complex clinical situations.

9.Strong analytical, organizational, and problem-solving ability.

10.Ability to work independently and collaboratively across disciplines.

Qualifications

MINIMUM EDUCATION REQUIRED:

• Minimum Requirement:High School diploma or GED
• Preferred:Associate degree or coursework in health sciences, human services, or medical services, or Medical Assistant Accreditation or Bachelors of Social Work

MINIMUM EXPERIENCE REQUIRED:

• Minimum 1–2 years of clinical experience in a medical office, telehealth, facility, or case management role.
• Proven background working with older adults or geriatric populations is highly preferred.

MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:

ADDITIONAL QUALIFICATIONS: (Preferred qualifications)

• Active Medical Assistant certification preferred (CMA, CCMA, or RMA) or

Family Makes Us Stronger. Our family, your family, one family. Committed to loving, giving, and caring. United in making a difference.

We are eager to connect with you! to get started at PruittHealth!

As an Equal Employment Opportunity employer, all qualified applicants will receive consideration without regard to race, color, religion, sex, national origin, disability, or veteran status.

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