Job Description

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The Health Navigator collaborates with members, family, healthcare providers, community resources and other members of the healthcare team to coordinate services and address barriers including access to health care, health literacy, transportation, wellness, gaps in care etc. The Health Navigator will guide members to achieve optimal and vibrant health by providing tools, information, and assistance to help understand their healthcare options, take control of their healthcare needs, bridge the current gap between social-economic and medical and behavioral needs, and navigate the otherwise often confusing steps along the path to efficient and effective care.

Responsibilities and Qualifications

• Identifying, facilitating, and securing access to needed healthcare, social services benefits and community resources. Assist members with navigating the steps along the path to efficient and effective care. Coordinate appointments with and transportation to physicians and non-physician providers to ensure timely and efficient delivery of diagnostic and treatment services when needed.
• Actively monitors incoming calls, conducts outgoing calls, and responds to voice mail requests in a timely manner. This could include, but is not limited to, closing gaps in care, HRAs, upcoming education/health events, and provider follow-up.
• Identify and assess members’ medical, behavioral, social, emotional, and financial needs.
• Effectively and efficiently utilize the resources available of social, economic, behavioral, and support systems and programs to connect at-risk members with appropriate community resources to address barriers and adherence. Conducts health education.
• Builds relationships with members, their families, and care givers and provides support in achieving their health care goals. Provide emotional support and/or referring to community-based or physician/provider for greater level of psychosocial intervention
• Completes education to assigned members and engages them into programs, completes interventions to meet member needs and identifies and refers candidates who require complex interventions to other programs/resources utilizing established criteria and documentation processes to support whole-person care.
• Completes surveys and assessments for assigned members to support health & wellness needs, and engagement in care programs.
• Delivers education—basic condition‑specific education, medication adherence, preventive care guidance, and navigation of available health benefits—to empower members in managing their health. Addresses identified gaps in care, reinforce provider care plans, and promote adherence to evidence‑based practices for members.
• Collaborates with interdisciplinary teams to support whole‑person care, improve quality outcomes, and enhance the member experience.
• Identifies and reports quality of care issues in accordance with established departmental policies and procedures. Maintains member confidentiality at all times.
• Documents all care navigator activities in the care management documentation system, according to established policies and procedures. Attends company and departmental meetings and training sessions as required.
• Assist with assigned population processes including, but not limited to, retrieving and assigning referrals, completing monthly reconciliation report between documentation system(s).

Skills:

• Critical thinking and problem-solving skills; and ability to handle critical situations.
• Excellent written, oral communication, listening, and organizational skills.
• Ability to operate a personal computer (PC), including proficiency in Microsoft Office Products. Ability to use computer system while conversing telephonically.
• Able to demonstrate strong customer service skills, including tact and diplomacy, both in person and telephonically when communicating with internal and external customers.
• Ability to appropriately prioritize workload and assignments and perform accurate, detailed and timely completion of assigned duties.
• Ability to work autonomously and as part of an interdisciplinary team
• Demonstrates sound judgment that affirms the rights and responsibilities of Member’s, families, health care professionals and health care organizations.

Knowledge:

• Knowledgeable on how to navigate all aspects of medical, behavioral, and social systems.
• Knowledge of NCQA standards for Population Health Management for health plan accreditation, DMAA standards for disease management and CMSA Standards of Practice for Case Management, Act 68, CMS Knowledge of current and emerging medical treatment modalities and best practice guidelines with the ability to analyze and interpret medical and benefit coverage interrelationships.
• Knowledge of adult learning principles, motivational interviewing and intrinsic coaching techniques.

Experience:

• At least three (3) years’ recent/related experience working in health and wellness promotion, inpatient or other appropriate clinical setting.
• Behavioral Health experience beneficial but not required.

Education and Certifications:

• Patient Navigation certification preferred or obtained within 1-year employment.
• Licensed Practical Nurse active license or degree in healthcare related field and 3 years of experience directly related to the duties and responsibilities specified.

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.