Managed Care Coordinator I

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

About The Position

Horizon Blue Cross Blue Shield of New Jersey empowers its members to achieve their best health. For over 90 years, the company has been New Jersey’s health solutions leader, driving innovations that improve health care quality, affordability, and member experience. Horizon serves 3.5 million people and prides itself on best-in-class employees, striving to maintain an innovative and inclusive environment. This position supports the Clinical Operations functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members, and Member Service Coordinators.

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.
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 (for Letter’s Team Only).
Perform initial screening of determination letters, ensuring clarity and compliance before distribution (for Letter’s Team Only).
Make sound, timely decisions under the direction and supervision of a designated Supervisor (for Letter’s Team Only).