Managed Care Coordinator I (Behavioral Health)

Horizon Blue Cross Blue Shield of New Jersey•Hopewell, NJ

5d•$44,600 - $59,745

About The Position

This position supports Clinical Operations and serves as a liaison among members, physicians, delegates, operational business members, and Member Service Coordinators. The role handles service-request intake and preparation, non-clinical information collection, case routing, benefit clarification, and coordination with providers, members, and Care Managers. Under clinical staff oversight, the coordinator may perform initial pre-certification screening using established scripts and workflows, but does not conduct utilization-management reviews requiring interpretation of clinical information. The position also assists members with provider access, service questions, appeals, care-management engagement, preventive health activities, appointments, and administrative requests. As part of the Letters Team, the coordinator reviews medical and administrative documentation and determination letters for accuracy, clarity, grammar, and regulatory compliance, making timely decisions under a designated Supervisor’s direction.

Requirements

High school diploma or GED.
Knowledge of medical terminology.
Good oral and written communication skills.
Ability to make sound decisions under the direction of a Supervisor.

Nice To Haves

Prefer 1–2 years of customer service or medical-support-related experience.
Medicaid case-management knowledge preferred.
Knowledge of contracts, enrollment, billing, and claims coding or processing preferred.
Knowledge of managed-care principles preferred.
Ability to analyze and resolve problems with minimal supervision preferred.
Ability to use a personal computer and applicable software and systems preferred.
Team-oriented approach and strong analytical and interpersonal skills.

Responsibilities

Review service requests for completeness; collect and transfer non-clinical data and obtain structured clinical data from physicians or patients.
Prepare, document, and route cases in the appropriate system for clinical review.
Contact members and providers by phone or correspondence to coordinate and clarify benefits, inquiries, and case completion.
Review professional medical or claim policy issues and claims in pending status.
Act as a liaison with providers, members, and Care Managers.
Perform other relevant tasks as assigned by Management.
Authorize services based on scripts or algorithms used for pre-review screening after clinical and non-clinical information is collected.
Conduct initial screening of pre-certification requests from physicians or members through calls or correspondence, following scripts and workflows under clinical staff oversight.
Assist members with finding providers, resolving problems, and answering questions about obtaining services or filing appeals.
Make outbound calls to engage members in Case Management and complete required health assessments, including IHS/HRA, CNA/CMNA, and MLTSS Eligibility Survey.
Educate members about preventive health activities and services.
Assist members with appointments with PCPs or specialists and transportation; handle requested PCP or demographic changes and replacement ID cards.
Triage and distribute referrals from Member Services and incoming provider faxes.
Review medical, dental, and vision claims and address gaps in members’ preventive care.
Review medical and administrative documentation for accuracy, grammar, and regulatory compliance.
Perform initial screening of determination letters to ensure clarity and compliance before distribution.
Make sound, timely decisions under the direction and supervision of a designated Supervisor.