Navigator

• Own escalations end‑to‑end: Lead resolution of complex PAs, denials, step therapy overrides, tier exceptions, continuation‑of‑therapy, and reauthorization timelines to keep treatment on schedule.
• Navigate benefits expertly: Determine the correct coverage path across medical vs. pharmacy benefits, formulary status, HCPCS/CPT coding, site‑of‑care, and specialty classification; advise partners on buy‑and‑bill vs. pharmacy fulfillment.
• Direct payer/PBM advocacy: Conduct targeted outreach to plans and PBMs to expedite decisions, correct errors, and secure patient access; prepare and submit clinical criteria summaries and appeals packets as needed.
• Clinic and provider support: Interface with clinicians and partner staff to identify missing documentation, clarify criteria, and align on next steps; coordinate with pharmacies for shipment, copay confirmation, and consent.
• Documentation and systems: Maintain precise status, outcomes, and next steps in EHR/CRM/Airtable; ensure audit‑ready records across all cases.
• Quality and mentorship: Coach BPO team members, perform case QA, and contribute to SOPs, checklists, and templates.
• Insights and improvement: Track payer behavior and bottlenecks, propose fixes, and partner with leadership on process and tooling improvements.

Senior Specialty Benefits Navigator

• The CKD RN Navigator is responsible for providing care coordination, education, and support to patients with chronic kidney disease (CKD) across various stages of the disease.
• This role serves as a liaison between patients, families, nephrologists, primary care providers, and the interdisciplinary healthcare team to optimize patient outcomes, promote self-management, and ensure seamless transitions of care.
• Leveraging an integrated technology platform, you are complemented by an entire interdisciplinary team including Nurse Practitioners, Nurse Care Managers, Care Coordinators, RN Educator, Dietitians, Pharmacists, Licensed Clinical Social Workers, and Psychiatrists.
• You will take the lead on identifying care gaps and navigating the patient through their CKD to ESKD journey in collaboration with a Care Coordinator, RN Educator, and the primary Nephrologist.
• You will play an essential role in helping patients achieve their goals through timely and proactive care planning toward a planned outpatient dialysis start with a permanent access or a care pathway of the patient’s choice driven by patient education and care team support.

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Senior Specialty Benefits Navigator

Senior Specialty Benefits Navigator

RN Navigator – CKD