Managed Care Coordinator I

Horizon Healthcare Services•Hopewell, NJ

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 supports utilization management and case management activities, including gathering and routing service-request information for clinical review, coordinating communications with members and providers, and helping members access care and resolve service-related questions. Non-clinical staff do not conduct utilization management reviews that require interpretation of clinical information; pre-certification screening is performed using scripts and workflows under clinical staff oversight.

Requirements

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

Nice To Haves

One to two years of customer service or medical support-related experience preferred.
Medicaid CM 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 player with 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.
Initiate callbacks and correspondence with members and providers to coordinate or clarify benefits and case completion.
Review professional medical or claim policy-related issues and claims in pending status.
Liaise with providers, members, and Care Managers.
Perform other relevant tasks assigned by Management.
For utilization management, collect clinical and non-clinical information and authorize services based on scripts or algorithms used for pre-review screening, within the role's non-clinical scope.
Screen incoming pre-certification requests from physicians or members by phone or correspondence using 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 (IHS/HRA, CNA/CMNA, MLTSS Elig Survey).
Educate members about preventive health activities and services.
Assist members with appointments with primary care physicians or specialists and with transportation arrangements.
Handle requested PCP or demographic changes and requests for new 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.