Plan Care Navigator

Pruitthealth Corporation; Norcross (GA); On-site; USD 42,000 - 56,000; Full time

Job summary

PruittHealth is seeking a Plan Care Navigator to serve as a primary contact for members, coordinating care and improving engagement under supervision of licensed providers. You will manage patient interactions, document through EHR systems, and support bridging to specialty care while maintaining HIPAA compliance.

The role emphasizes problem solving, structured assessments, and proactive outreach to prevent hospitalizations, with responsibilities spanning scheduling, referrals, and

Qualifications

• High school diploma or GED required.
• Preferred: Associate degree or coursework in health sciences or related fields.
• 1–2 years clinical experience in medical office, telehealth, facility or case management.
• Active Medical Assistant certification preferred (CMA, CCMA, or RMA) or equivalent.

Responsibilities

• Handle inbound calls, assess member needs and provide guidance.
• Provide live phone support before appointments.
• Coordinate care workflows from outreach to case resolution.
• Escalate to RNs for abnormal vitals or medical history concerns.
• Document all patient interactions in EHRs and call scripts.

Skills

Referral / prior authorization process

CMS regulations knowledge

HIPAA compliance

Communication skills

Organization & multitasking

Problem solving

Independent & collaborative work

Education

Associate degree or coursework in health sciences

Medical Assistant accreditation or CMA/CCMA/RMA

Bachelor of Social Work (BSW)

High School diploma or GED

Tools

EMR

Care management platform

Microsoft Office

Reporting tools

Job description

Job Description - Plan Care Navigator (2612011)

Plan Care Navigator - 2612011

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
11. Assisting with receipt of durable medical equipment
12. Complete welcome calls and scheduling of health risk assessments
13. Interdisciplinary care team meeting support
14. Monitor patient health data and clear incoming vital sign readings via Remote Patient Monitoring (RPM) software.
15. Escalate clinical flags or urgent patient updates to supervising nurses or physicians according to clinic protocols.
16. 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.
17. 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.

ADDITIONAL 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.

For Florida Job Postings Only:

For more information regarding Florida’s Care Provider Background Screening Clearinghouse Education and Awareness, please visit https://info.flclearinghouse.com