Managed Care Coordinator II

Horizon Healthcare Services•Hopewell, NJ

About The Position

The Managed Care Coordinator II supports Clinical Operations and serves as a liaison among members, physicians, delegates, operational business members, and member service coordinators. The role provides leadership and guidance to non-clinical team members and handles escalated issues and problems. The coordinator reviews service requests for completeness, collects and transfers non-clinical information, obtains structured clinical data from physicians or patients, and prepares and routes cases for clinical review. The role coordinates and verifies benefits, treatment courses, and case completion through calls and correspondence with members and providers. It also supports onboarding and training for newly hired Managed Care Coordinators I. For utilization management, the role may authorize services based on scripts or algorithms used for pre-review screening after clinical and non-clinical information is collected. Non-clinical staff do not conduct utilization review activities that require interpretation of clinical information. The coordinator performs initial screening of precertification requests using established scripts and workflows under clinical or supervisory oversight. For case management, the coordinator helps members find providers, resolve problems, and understand how to obtain services or file appeals. The role makes outbound calls to engage members and complete health assessments, distributes new case assignments to clinical staff, reviews claims and preventive-care gaps, educates members about preventive health, and assists with appointments and related needs. Other tasks may include processing primary care provider, demographic, and ID-card requests, and triaging and distributing referrals and provider faxes. Additional duties apply to specific teams. Behavioral Health Clinical Operations requires one holiday shift per year. The Letters Team reviews medical and administrative documentation and determination letters for accuracy, grammar, clarity, and regulatory compliance, and makes timely decisions under a designated supervisor. Medically Certified Spanish Translators also review documents in English and Spanish, translate clinical and non-clinical documents between those languages, and assist with onboarding and training on language protocols and workflows. Some travel may be required. Employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Requirements

High school diploma or GED.
3–5 years of customer service experience.
Knowledge of medical terminology.
Good oral and written communication skills.
Ability to make sound decisions under the direction of a supervisor.
Knowledge of clinical standards of care and Star measures.
Operational knowledge of health care delivery systems and the health insurance industry.
Appreciation for strategic planning.
For the Letters Team and medically certified Spanish translator roles, knowledge of NCQA accreditation standards and state and federal laws applicable to health plan appeals and grievances.
For the Letters Team and medically certified Spanish translator roles, knowledge of CMS and state regulatory requirements.
For the medically certified Spanish translator role, medical certification translator education.
Behavioral Health Clinical Operations colleagues are required to work one holiday shift per year.
Must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Nice To Haves

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.
Team-player approach, strong analytical skills, and interpersonal skills.

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 calls and correspondence with members and providers to coordinate and verify benefits, courses of treatment, and case completion.
Collect and collate information to address escalated phone and correspondence inquiries, and investigate and resolve those inquiries.
Assist with onboarding and training newly hired Managed Care Coordinators I.
Act as a liaison among providers, members, and Care Managers.
For utilization management, perform initial screening of precertification requests using established scripts and workflows under clinical or supervisory oversight; authorize services based on scripts or algorithms used for pre-review screening when applicable.
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 health assessments, including IHS/HRA, CNA/CMNA, and MLTSS Eligibility Survey assessments.
Distribute new case assignments to Case Management Clinical Staff.
Review medical, dental, and vision claims and address gaps in members' preventive care.
Educate members about preventive health activities and services.
Assist members with appointments with their primary care providers and specialists, and with transportation needs.
Process primary care provider and demographic changes and requests for new ID cards.
Triage and distribute referrals from Member Services and incoming provider faxes.
For the Letters Team, review medical and administrative documentation and determination letters for accuracy, grammar, clarity, and regulatory compliance; make sound, timely decisions under a designated supervisor.
For medically certified Spanish translators, review documentation in English and Spanish, translate clinical and non-clinical documents between English and Spanish, and support onboarding and training on language protocols and workflows.
Perform other relevant tasks as assigned by management.