Managed Care Coordinator I

Horizon Healthcare Services•Hopewell, NJ

3d•Onsite

About The Position

This position supports the Clinical Operations functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators. The role involves reviewing service requests for completeness, collecting and transferring non-clinical data, and acquiring structured clinical data from physicians/patients. It also includes preparing and routing cases for clinical review, initiating communication with members and providers to coordinate benefits and case completion, and reviewing professional medical/claim policy related issues or claims in pending status. The position serves as a liaison with providers, members, and Care Managers, and performs other relevant tasks as assigned by Management. Specific duties include initial screening for pre-certification requests based on scripts and workflows under clinical staff oversight, and assisting members with finding providers, resolving problems, and answering questions related to services or appeals. This includes engaging members in Case Management, completing health assessments, educating members on preventive health, assisting with appointments and transportation, and handling PCP/demographic changes and ID card requests. The role also involves triaging referrals and reviewing medical, dental, and vision claims to address gaps in preventative care.

Requirements

High School Diploma/GED required.
Requires knowledge of medical terminology
Requires Good Oral and Written Communication skills.
Requires ability to make sound decisions under the direction of Supervisor.
Team Player, Strong Analytical, Interpersonal Skills.

Nice To Haves

Prefer 1-2 years customer service or medical support related position.
Preferred – Medicaid CM.
Prefer knowledge of contracts, enrollment, billing & claims coding/processing.
Prefer knowledge Managed Care principles.
Prefer the ability to analyze and resolve problems with minimal supervision.
Prefer the ability to use a personal computer and applicable software and systems.

Responsibilities

Performs review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients.
Prepare, document and route cases in appropriate system for clinical review.
Initiates call backs and correspondence to members and providers to coordinate and clarify benefits.
Upon completion of inquiries initiate call back or correspondence to Physicians/Members to coordinate/clarify case completion.
Reviewing professional medical/claim policy related issues or claims in pending status.
Acts as liaison with providers, members and Care Managers.
Perform other relevant tasks as assigned by Management.
Handles initial screening for pre-certification requests from physicians/members via incoming calls or correspondence based on scripts and workflows, and under the oversight of clinical staff.
Assists members with finding providers, resolving problems and answering questions regarding anything from how to obtain services to how to file an appeal.
Makes outbound calls to in order to engage members in Case Management and to complete the necessary health assessment(s) (IHS/HRA, CNA/CMNA, MLTSS Elig Survey.)
Educates members regarding preventive health activities and services.
Assists member to make appointments with their PCP, specialists, and/or transportation, etc.
Handle PCP, demographic changes and/or new ID cards as requested by members.
Triage and distribute referrals from Member Services and incoming faxes from providers.
Reviews medical, dental and vision claims and address gaps in member's preventative care.