Medical Navigation Coordinator
Position Summary:
The Medical Navigation Coordinator is responsible for managing and tracking procedural
and pharmaceutical cost-saving initiatives, supporting clinical
decision-making, and ensuring compliance with insurance and CMS guidelines.
This role involves synthesizing patient information and generating detailed
reports to support operational efficiency and patient care outcomes.
Key Responsibilities:
- Review and synthesize patient clinical data to support determinations aligned with CMS guidelines and insurance plan requirements.
- Analyze pre-certification reports and prescription fill data to identify opportunities for proactive member engagement and cost-effective care solutions.
- Educate members on cost-saving opportunities, including the use of alternative facilities to reduce out-of-pocket expenses.
- Coordinate appointment scheduling and supply ordering to ensure continuity of care and adherence to treatment plans.
- Negotiate payment arrangements on behalf of both payers and members; secure payment vouchers as needed.
- Cultivate strong relationships with vendors, providers, and stakeholders to streamline care navigation and enhance member outcomes.
- Develop and maintain a comprehensive suite of
procedural and pharmaceutical tracking reports, including:
- Weekly and Monthly Savings Tracking Reports
- Engagement Reports
- MediReview and Precertification Reports
- Rx Utilization and Cost-Savings Reports
- Monitor and analyze trends across pharmacy and procedural data to identify and implement cost-saving strategies.
- Collaborate with interdisciplinary teams to ensure accurate data collection, reporting, and care coordination.
- Provide patient and family education to support recovery and optimize physical, emotional, and cognitive well-being in home and community settings.
Qualifications:
- Clinical or administrative background in healthcare
- Strong analytical and reporting skills with proficiency in healthcare data systems.
- Familiarity with CMS regulations, insurance processes, and pharmaceutical cost-containment strategies.
- Excellent communication and organizational skills.