Manager, Patient Navigation

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• The Manager, Patient Navigation leads the day-to-day operations of the Patient Navigation function, a centralized, high-compliance call center model responsible for three Phase 1 workstreams: Non-CPL (Coordinated Provider List)/Out-of-Network Requests, Care Plan Non-Adherence, and Voluntary PCP Switches. This role manages a team of Tier 1 Patient Navigators and Tier 2 RN/Licensed Social Worker staff, owns quality and compliance oversight across 100% recorded interactions, and partners closely with a borrowed Medical Director who provides Tier 3 clinical sign-off on a limited, shared-capacity basis.
• The Manager, Patient Navigation is accountable for ensuring every ticket — regardless of originating channel (Careline & Field-Initiated Tickets, Patient-Initiated Appeals for Clinical Review, or Non-CPL/Out-of-House Requests) — is triaged, worked, and closed-loop documented in a manner that satisfies CMS delegation-oversight standards and the terms of ChenMed's full-risk delegation agreements with its Medicare Advantage payers.
• This role also owns performance reporting for the function — tracking volume, conversion, staffing utilization, and compliance metrics — and works cross-functionally with Community Nursing, APA (Acute & Post-Acute), Chen-K, Behavioral Health, and Enrollment/Eligibility Operations on hand-offs for cases outside Patient Navigation's Phase 1 scope. ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

• •Manages day-to-day operations of the Patient Navigation function, including staffing, scheduling, and workload distribution across Tier 1 Patient Navigators and Tier 2 RN/Licensed Social Worker staff.
• •Oversees intake and triage across all three in-scope workstreams (Non-CPL/Out-of-Network Requests, Care Plan Non-Adherence, and Voluntary PCP Switches), ensuring tickets from every originating channel are routed, worked, and documented to a closed-loop standard — with the patient, the referring care team, and the compliance record all reflecting the resolution.
• •Conducts call monitoring and documentation audits across 100% recorded interactions to ensure ongoing compliance with CMS delegation-oversight standards (42 CFR 422.504), non-discrimination requirements (42 CFR 422.110), and the specific terms of ChenMed's full-risk Medicare Advantage delegation agreements.
• •Implements and maintains a maker/checker control on any case with panel impact or a clinical determination, ensuring the staff member recommending an action is never the sole approver of that action.
• •Partners with the Medical Director — a borrowed, partial-FTE resource — to coordinate Tier 3 clinical sign-off efficiently, managing the cadence and volume of cases requiring that review given the Medical Director's limited, shared capacity.
• •Tracks and reports team performance against volume, conversion, staffing, and compliance metrics (including FTE utilization by tier, OON and Non-Adherence conversion rates, and PCP-switch processing timeliness) to senior leadership on a regular cadence.
• •Monitors outcomes for any pattern suggesting a correlation with patient risk scores or cost — particularly for cases resulting in a patient leaving the panel or being reclassified — and escalates any such pattern immediately, consistent with full-risk delegation compliance obligations.
• •Coaches and develops Tier 1 and Tier 2 staff based on call reviews and documentation audits; leads training on process, script, and compliance updates.
• •Collaborates with Community Nursing, APA, Chen-K, Behavioral Health, and Enrollment/Eligibility Operations on hand-offs for tickets outside Patient Navigation's Phase 1 scope (e.g., unreachable-patient cases, complex clinical needs, roster/eligibility hygiene, or disruptive-behavior reports).
• •Identifies and escalates systemic operational issues — including capacity constraints, tier-mix mismatches, or gaps in feeder-system data — to leadership with data-driven recommendations.
• •Maintains and evolves the standard operating procedures, escalation criteria, and QA scoring rubric for the function as workstreams, volumes, or compliance requirements change.
• •Performs other duties as assigned and modified at manager's discretion.

KNOWLEDGE, SKILLS AND ABILITIES:

• •Demonstrated ability to manage a call center or patient-facing operations team, ideally within a healthcare, health plan, or managed care setting.
• •Strong working knowledge of CMS Medicare Advantage compliance concepts relevant to the function — including non-discrimination requirements, delegation oversight, grievance and appeals boundaries, and member-choice protections — sufficient to train and audit staff against them.
• •Ability to interpret operational and financial data (ticket volume, conversion rates, FTE utilization, cost avoidance) and present findings clearly to senior leadership.
• •Excellent coaching, feedback, and team-development skills.
• •Ability to manage cross-functional relationships with clinical teams (Community Nursing, APA, Chen-K, Behavioral Health) and with Enrollment/Eligibility Operations.
• •Sound judgment balancing patient experience, compliance risk, and cost considerations; comfortable escalating ambiguous cases rather than guessing.
• •Demonstrated ability to provide leadership to staff and to build the trust and respect of leaders, colleagues, and cross-functional partners.
• •Understands and is committed to maintaining the highest level of confidentiality (HIPAA).
• •Excellent verbal and written communication skills.
• •Proficient in Microsoft Office (particularly Excel, for tracking volume and ROI metrics) and case-management/CRM/QA software.
• •This job requires use and exercise of independent judgment.
• •Spoken and written fluency in English; bilingual preferred.

EDUCATION AND EXPERIENCE CRITERIA:

• •BA/BS degree in Healthcare Administration, Business, or a closely related field required; additional experience above the minimum may be considered in lieu of the required education on a year-for-year basis.
• •Master's degree a plus.
• •Minimum three to five (3-5) years of experience in healthcare operations, call center management, or patient/member services, including at least one to two (1-2) years in a supervisory or people-management capacity.
• •Prior experience working in a Medicare Advantage or managed care environment strongly preferred.
• •Experience with quality assurance/call-monitoring programs in a compliance-sensitive environment preferred.
• •Experience partnering with clinical staff (RN, licensed social work, or medical director-level) in a matrixed or borrowed-resource staffing model a plus.



 PAY RANGE:

$76,732 - $109,617 Salary The posted pay range represents the base hourly rate or base annual full-time salary for this position. Final compensation will depend on a variety of factors including but not limited to experience, education, geographic location, and other relevant factors. This position may also be eligible for a bonuses or commissions.

EMPLOYEE BENEFITS

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