Managed Care Coordinator I

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

1d•$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 coordinator reviews service requests for completeness, collects and transfers non-clinical data, obtains structured clinical data from physicians and patients, and prepares, documents, and routes cases for clinical review. The position also coordinates and clarifies benefits and case completion with members and providers, reviews professional medical or claim policy issues and claims in pending status, and performs other tasks assigned by management. For utilization management, the coordinator may authorize services based on scripts or algorithms after collecting clinical and non-clinical information. Non-clinical staff do not conduct utilization-management reviews that require interpretation of clinical information. Under clinical staff oversight, the coordinator performs initial screening of precertification requests received from physicians or members by phone or correspondence, following scripts and workflows. For case management, the coordinator helps members find providers, resolve problems, and understand how to obtain services or file appeals. The role includes outbound calls to engage members and complete health assessments, educating members about preventive health activities and services, helping arrange appointments and transportation, handling requested PCP or demographic changes and ID cards, triaging and distributing referrals and provider faxes, and reviewing medical, dental, and vision claims to address gaps in preventive care.

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.
Team player with strong analytical and interpersonal skills.

Nice To Haves

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

Responsibilities

Review service requests for completeness; collect and transfer non-clinical data and obtain structured clinical data from physicians and 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.
Act as a liaison with providers, members, and Care Managers.
Authorize services based on scripts or algorithms after collecting clinical and non-clinical information, within the limits of the non-clinical role.
Screen initial precertification requests received from physicians or members by incoming calls or correspondence, following scripts and workflows under clinical staff oversight.
Assist members with finding providers, resolving problems, obtaining services, and understanding how to file an appeal.
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.
Help members arrange appointments with PCPs or specialists and arrange transportation as needed.
Handle requested PCP and 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.
Perform other relevant tasks as assigned by Management.