Managed Care Coordinator I

CLS Health PLLC•Webster, TX

About The Position

About CLS Health CLS Health is a growing healthcare system in Houston, Texas that is taking a different approach to healthcare. We are a physician-led healthcare group that focuses on providing patients with holistic, multispecialty care. We're a dynamic team on a mission to provide better healthcare options for Houstonians! Job Overview: The Managed Care Coordinator I is responsible for coordinating and ensuring the delivery of high-quality, cost-effective healthcare services to members. This role involves working closely with healthcare providers, patients, and insurance companies to facilitate care, manage resources, and support the healthcare team in achieving optimal patient outcomes.

Requirements

Bachelor’s degree in Healthcare Administration, Nursing, Public Health, or related field preferred.
2+ years of healthcare experience in care coordination, population health, or value-based care.
Knowledge of Medicare Advantage, HCC coding, and quality measures preferred.
Experience with EHR systems and Microsoft Excel.
Strong communication and organizational skills.

Nice To Haves

Knowledge of Medicare Advantage, HCC coding, and quality measures preferred.

Responsibilities

Ensure all clinical operations comply with Medicare and Medicaid guidelines and other manage care policies.
Adhere to all state, accreditation standards and regulatory guidelines which include HIPAA guidelines and NCQA accreditation.
Conduct outgoing calls to patients to arrange appointments.
Make outgoing calls to pharmacies to confirm each patient’s medication adherence.
Prepare charts for providers, highlighting managed care directives that need attention.
Reviewing medical records and treatment plans to ensure they align with the guidelines and policies of the managed care organization.
Communicates with physicians, discharge planners and others to process referrals, authorization for services, and capture data related to utilization.
Review ICD-9 and HCPCS codes to ensure accurate coding on claims.
Verify CPT codes to determine if authorization is needed and distinguish between network and non-network providers.
Submit attestation forms through insurance portals.
Document confidential patient information, upholding the highest standards of privacy in accordance with HIPAA regulations.
Submit documentation to address and close care gaps for patients via insurance portals.