Plan Care Navigator

PruittHealth; Athens, Northern (GA, KY); Hybrid; USD 42,000 - 62,000; Full time

Job summary

PruittHealth is seeking a Plan Care Navigator to support members enrolled in PruittHealth Premier. You will coordinate clinical care, perform structured phone assessments, document in the EHR, and help members access services while focusing on quality and outcomes.

You will work with interdisciplinary teams, schedule follow-ups, monitor health data, and escalate urgent concerns to RNs or physicians. Strong communication and organization are essential.

Qualifications

• Understanding referral and prior authorization processes.
• Knowledge of PruittHealth Premier Plan benefits and policies.
• Familiarity with CMS regulations and Model of Care requirements.
• HIPAA compliance and medical data security.
• Proficiency with EMR and reporting tools.
• Excellent written and verbal communication.
• Ability to manage high call volumes and stay organized.
• Ability to work independently and with teams.

Responsibilities

• Handle inbound member calls and guide to appropriate resources.
• Document all interactions in the EHR accurately.
• Coordinate medical services among physicians, labs, and providers.
• Schedule follow-ups, refills, and referrals.
• Escalate urgent clinical concerns to supervising RNs/physicians.
• Assist with transportation scheduling and RPM-related tasks.

Skills

Referral process

CMS regulations

HIPAA compliance

EMR proficiency

Care management platforms

Microsoft Office

Strong communication

Organizational skills

Education

High School diploma

Assoc. degree / health sciences

Medical Assistant cert (preferred)

Tools

EMR system

Care management platform

Microsoft Office

Reporting tools

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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