Managed Care Coordinator II

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

10h•$50,100 - $67,095

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. Responsible for providing leadership and guidance to non-clinical team and handle escalated issues/problems.

Requirements

High School Diploma/GED required.
3-5 years customer service experience.
Medical certification translator education (Letter’s Team, Medically Certified Spanish Translator only).
Requires knowledge of medical terminology
Requires Good Oral and Written Communication skills
Requires ability to make sound decisions under the direction of Supervisor
Requires knowledge of clinical standards of care, and Star measures.
Requires operational knowledge of health care delivery systems and health insurance industry.
Requires appreciation for strategic planning.
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware.

Nice To Haves

Prefer knowledge of contracts, enrollment, billing & claims coding/processing
Prefer knowledge Managed Care principles
Requires knowledge of NCQA accreditation standards as well as state and federal laws applicable to health plan appeals and grievances. (Letters Team, Medically Certified Spanish Translator)
Requires knowledge of CMS and state regulatory requirements. (Letters Team, Medically Certified Spanish Translator only)
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 verify benefits and courses of treatment.
Collect and collate information required to handle escalated phone/correspondence inquiries.
Upon completion of inquiry investigation/resolution, initiate call back or correspondence to physicians/members to coordinate/verify case completion.
Assist with on-boarding and training of newly hired Managed Care Coordinators I.
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.
Performs initial screening of precertification requests from physicians/members received via incoming calls or correspondence using established scripts and workflows under the oversight of clinical /supervisory 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).
Distributes new case assignments to the Case Management Clinical Staff.
Reviews medical, dental and vision claims and address gaps in member's preventative care.
Educates members regarding preventive health activities and services.
Assists members making appointments with their PCP, specialists, and/or transportation, etc. Process PCP, demographic changes and new ID cards as requested by members.
Triage and distribute referrals from Member Services and incoming faxes from providers.
Required to work one holiday shift per year (Addendum For Behavioral Health Clinical Operations Only).
Review medical and administrative documentation for accuracy, grammar, and compliance with regulatory standards (Addendum for Letter’s Team Only).
Perform initial screening of determination letters, ensuring clarity and compliance before distribution (Addendum for Letter’s Team Only).
Make sound, timely decisions under the direction and supervision of a designated Supervisor (Addendum for Letter’s Team Only).
Review medical and administrative documentation for accuracy, grammar, and compliance with regulatory standards in both English and Spanish (Medically Certified Spanish Translator Only).
Translate clinical and non-clinical documents between English and Spanish, ensuring precise medical terminology and context (Medically Certified Spanish Translator Only).
Assist in the onboarding and training of new Managed Care Coordinators, providing guidance on language protocols and workflow processes (Medically Certified Spanish Translator Only).