The Outpatient Navigator reviews and monitor patient’s utilization of health care services with the goal of maintaining high quality, cost-effective care. The role includes providing the medical and utilization expertise necessary to evaluate the appropriateness and efficiency of medical services and procedures. This includes scheduling clinical services, providing referral authorization, concurrent review, appropriate referral to case management, and high dollar claims review.

Essential Duties and Responsibilities

• Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided.
• Assists in receiving calls and messages from medical offices and patients to schedule tests and/or procedures.

• Performs concurrent and retrospective reviews on hospital and clinic cases including referrals and prior authorizations, plans available covered services including identifying alternative levels of care that may be covered.
• Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.
• Obtains prior authorization or pre-certification of services to be rendered as required by Greene County General Hospital and the MyClinics.
• Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care.
• Monitors all utilization reports to assure compliance with reporting and turnaround times.
• Addresses and works to resolve prior authorization issues/problems with the Business Office Supervisor and the various department directors.  
• Coordinates identification and reporting of potential high dollar/utilization cases to reinsurer and finance department for appropriate reserve allocation.
• Consults with physicians, health care providers and outside agencies regarding testing and procedures ordered by providers.
• Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.
• Clarifies health plan medical benefits, policies and procedures for patients, physicians, medical office staff, contract providers, and outside agencies.
• Actively participates in the discussion and notification processes that result from the clinical utilization reviews with the Clinics. Prepares CMS-compliant notification letters of non-certified and negotiated days within the established time frames. Reviews all non-certification files for correct documentation.
• Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.
• Effectively supports other prior authorization coordinators by providing back-up coverage while he/she is out on leave.
• Assists with the completion of patient estimates as required by the price transparency standards.
• Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.
• Demonstrates clear ownership of workplace and patient safety.
• Reports mistakes, near misses, adverse events and quality and safety concerns.
• Participates in the development and implementation of safety and quality improvement activities.
• Protects patient confidentiality and abides by all HIPAA and privacy laws.

• Other duties as assigned.

Job Requirements

Education:  High School Diploma or GED required.

Certification/Licensure:  N/A

Experience:  Minimum of three (3) years of clinical experience required and 5 years managed care or equivalent health plan experience, preferred.  Ability to read, analyze, and interpret documents, reports, technical procedures, governmental regulations, and correspondence; ability to write routine reports and correspondence; and ability to present information in one-on-one or to small groups.  Must have excellent oral and written communication skills.  Must have excellent computer skills and ability to learn new systems.  Strong attention to detail, organizational skills and interpersonal skills.

Physical Requirements:  Frequent sitting, walking and standing.  Able to convey detailed or important instructions or ideas accurately to patients or their families. Ability to stoop, bend and reach.  Occasionally required to lift and/or move up to 20 lbs.