ER Care Navigator

ER CARE NAVIGATOR
Level: Supervisor
Leadership Responsibility: Individual Contributor
Reporting Line: Head - Provider Services, Customer Care
Position Accountability Statement
The ER Care Navigator, is responsible for ensuring efficient utilization of emergency room (ER) resources

by collaborating with hospital ER staff to assess case urgency, managing LOA issuance and redirection

when appropriate, addressing inquiries and concerns related to ER services, delivering clear explanations

of benefits to members, and supporting steerage and primary care network (PCN) initiatives to enhance

healthcare efficiency and member experience.

Broad Responsibility Highlights
The following broad responsibility statements are representative of the basic expectations about the role

or function. Depending on business needs and exigencies, these responsibility statements may be

modified. Critical to any leadership function is the need to demonstrate flexibility and agility in adapting to

the changing requirements of the business.

• Support members by collaborating with hospital ER staff to assess case urgency, ensuring that

only qualified emergency cases, whether Outpatient or In-patient, are directed to the Emergency

Room. This involves coordinating with healthcare professionals to prioritize critical cases, and

allocating resources for timely and effective care. The focus on prioritizing emergency cases aims

to optimize ER efficiency and improve patient outcomes.

• Provide assistance to members during Emergency Room (ER) visits by efficient/ timely issuance

of Letters of Authorization (LOA) to facilitate access to medical services. Implement redirection

strategies as needed to direct non-emergency cases to alternative healthcare facilities or

services. This includes offering guidance on available healthcare options, and ensuring smooth

transitions to optimize the suitability and efficiency of care delivery.

• Handle various concerns and inquiries related to Emergency Room (ER) availment and

miscellaneous items. Provide assistance and clarification to members on ER services, eligibility,

coverage, and procedures. By effectively addressing these concerns, ensure members are

well-informed and supported, contributing to a positive patient experience and optimal ER

resource utilization.

• Facilitate seamless transitions for patients from the Emergency Room (ER) to the Inpatient Team

by endorsing cases for admission. Collaborate with healthcare professionals to assess patient

needs, compile required documentation, and communicate relevant information to the Inpatient

Team. Ensure timely and appropriate care upon admission, promoting continuity of care and

optimal patient outcomes.

• Provide detailed explanations of benefits and review coverage and non-coverage based on their

benefit provision. Additionally, offer direct assistance to members who are unaccompanied,

addressing any questions or concerns they may have, ensuring they receive the necessary

support and understanding.

• Promotion and Steerage to our Primary Care Networks. Encourage and assist members in

visiting our Primary Care Networks (PCNs), providing full support and guidance. This includes

advocating for PCN benefits and helping members understand available services.

• Act as gatekeeper and screen for unnecessary charges in accordance with our memo. This

involves carefully reviewing charges and expenses to ensure compliance with established

guidelines and protocols. By diligently fulfilling this role, we aim to prevent unnecessary costs and

uphold financial accountability within the organization.

• Enhance cost savings by directing non-emergency cases to more suitable healthcare services or

facilities. This includes evaluating case urgency and guiding individuals towards alternative care

options. Through this approach, we strive to maximize resource utilization, reduce unnecessary

expenses, and promote overall efficiency and financial sustainability within the organization.

Desired Skills And Competencies

• Effective Prioritization and Timely Decision Making: Ability to prioritize tasks efficiently and

make timely decisions to address issues promptly.

• Assertive Negotiation and Influencing Skills: Capability to negotiate effectively and influence

Maxicare business results positively.

• Concise Communication: Skill in conveying information clearly and succinctly to ensure

effective communication.

• Conflict Resolution and Interdisciplinary Collaboration: Proficiency in resolving conflicts and

collaborating with interdisciplinary teams to achieve common goals.

• Efficient and Proactive Customer Service: Capacity to provide proactive and personalized

customer service efficiently, demonstrating empathy and active listening.

• In-Depth Knowledge on Products, Policies, and Procedures: Thorough understanding of

Maxicare products, policies, and procedures, with attention to detail and a willingness to share

knowledge.

• Critical Thinking and Critical Decision-Making: Ability to think critically and make sound

decisions based on thorough analysis and evaluation.

• Adaptability and Independent Decision-Making: Flexibility to adapt to changing circumstances

and make independent decisions as needed.

• Empathetic Communication and Influencing Skills: Ability to communicate empathetically and

influence stakeholders effectively to achieve desired outcomes.

Professional Qualification

• Preferably with at least 5 years experience in a customer service role
• Preferred industry orientation: Healthcare, Insurance, Pharmaceuticals, FMCG, or any service-oriented industry