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Care Navigation NEW

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Care Navigation helps members navigate healthcare complexities through personalized research, guidance, and advocacy. Learn how to collect, document, and respond to member questions, issues, and complaints while ensuring cost-effective healthcare decisions.

What is Care Navigation?

Care Navigation is a specialized service that provides members with personalized healthcare guidance, helping them make informed decisions about their care while optimizing costs and outcomes. Care Navigators serve as healthcare advocates, researchers, and coordinators for complex member needs.

Case Creation Methods

Care Navigation cases can be initiated through two primary pathways, each serving different member interaction scenarios:

Member-Initiated Cases

Members can create cases directly through the platform when they need assistance with healthcare decisions, benefit questions, or care coordination. These cases are typically self-service requests where members provide their initial information and needs.

Direct platform submission
Member-provided initial details
Self-identified needs and concerns
Automatic case assignment workflow

Support-Initiated Cases

Support representatives can create cases during member interactions when complex issues require specialized Care Navigator expertise. These cases often emerge from initial support conversations that reveal deeper navigation needs.

Created during support interactions
Complex issues requiring expertise
Escalation from basic support
Detailed context from initial conversation

Essential Case Properties

Each Care Navigation case contains critical information that enables effective member assistance and comprehensive case management:

Case Property Components

Member Information

Direct access to member profile, contact details, and impersonation capabilities for personalized support.

Case Description

Detailed summary and ongoing updates about the member's healthcare needs and concerns.

Cost Savings

Tracking of financial impact, savings achieved, and cost-effectiveness metrics.

Messages

Complete communication history between navigator and member.

Internal Notes

Private documentation and observations visible only to support staff.

File Attachments

Documents, forms, and resources shared by both members and navigators.

Case Status Management

Understanding case statuses helps track progress and manage workflow effectively:

New / Unassigned: Case has been created and awaits navigator assignment
In Progress: Navigator is actively working with the member
Resolved: Recommendations provided and member needs met
Closed: Case complete and fully documented

Status Transitions

Cases typically move from "New" to "In Progress" when a navigator accepts the case, then to "Resolved" when recommendations are provided and member needs are met, and finally to "Closed" when the case is complete and documented.

Daily Care Navigation Workflow

Care Navigators follow a structured workflow to ensure comprehensive member support:

Standard Navigator Daily Process

Case Review

Review new cases, prioritize urgent matters, and plan daily activities

Member Outreach

Contact members to understand their needs and gather relevant information

Research & Analysis

Investigate options, compare costs, and evaluate quality metrics

Recommendations

Present findings and recommendations to members with clear explanations

Follow-up

Monitor member progress and provide ongoing support as needed

Documentation

Update case records with detailed notes and outcomes

Cost Savings Documentation

Care Navigation success is often measured by cost savings achieved for both members and health plans. Proper documentation requires capturing several key metrics:

Required Savings Documentation

Total Charges: Original quoted amount for services
Recommended Costs: Costs at recommended provider/facility
Member Savings: Out-of-pocket cost reduction for the member
Plan Savings: Insurance plan cost reduction
Quality Metrics: Comparative quality scores and ratings
Audit Information: Documentation supporting savings calculations

Care Navigation Best Practices

Communication Excellence

Respond to member inquiries within established timeframes
Use clear, non-medical language when explaining options
Provide multiple communication options (phone, email, secure messaging)
Confirm member understanding before proceeding

Documentation Standards

Record all member interactions with timestamps
Document research methodology and sources
Include rationale for recommendations
Track outcomes and follow-up activities

Quality Assurance

Verify provider credentials and network status
Cross-reference cost estimates with multiple sources
Consider member-specific factors (location, preferences, medical history)
Review cases for completeness before closing

Member Search Guide Escalation Procedures Member Impersonation