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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We’re ChenMed and we’re transforming healthcare for seniors and changing America’s healthcare for the better.  Family-owned and physician-led, our unique approach allows us to improve the health and well-being of the populations we serve. We’re growing rapidly as we seek to rescue more and more seniors from inadequate health care. 

ChenMed is changing lives for the people we serve and the people we hire.  With great compensation, comprehensive benefits, career development and advancement opportunities and so much more, our employees enjoy great work-life balance and opportunities to grow.  Join our team who make a difference in people’s lives every single day.

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