Managed Care Coordinator I

Horizon Healthcare Services•Hopewell, NJ

2d•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 for coordination and clarification, 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 fall under Utilization Management, Case Management, and the Letters Team.

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.

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.
Team Player, Strong Analytical, Interpersonal Skills.

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.
Upon collection of clinical and non-clinical information MCC can authorize services based upon scripts or algorithms used for pre-review screening. Non Clinical staff members are not responsible for conducting any UM review activities that require interpretation of clinical information.
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.
Review medical and administrative documentation for accuracy, grammar, and compliance with regulatory standards.
Perform initial screening of determination letters, ensuring clarity and compliance before distribution.
Make sound, timely decisions under the direction and supervision of a designated Supervisor.