MANAGED CARE COORDINATOR II

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

2d•$50,100 - $67,095

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 role provides leadership and guidance to non-clinical team members and handles escalated issues and problems. It performs administrative and non-clinical coordination activities in utilization management and case management; non-clinical staff do not conduct utilization management reviews requiring interpretation of clinical information. The position may require some travel. 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 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 Letters Team and Medically Certified Spanish Translator roles: knowledge of CMS and state regulatory requirements.
For Medically Certified Spanish Translator roles: medical certification translator education.
May require some travel.

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 qualities and strong analytical and interpersonal skills.

Responsibilities

Review service requests for completeness, collect and transfer non-clinical data, and obtain structured clinical data from physicians or patients.
Prepare, document, and route cases in the appropriate system for clinical review.
Initiate callbacks and correspondence with members and providers to coordinate and verify benefits and courses of treatment.
Collect and collate information needed to handle escalated phone and correspondence inquiries; after investigating and resolving inquiries, contact physicians or members to coordinate or verify case completion.
Assist with onboarding and training newly hired Managed Care Coordinators I.
Act as a liaison with providers, members, and Care Managers.
Authorize services based on scripts or algorithms used for pre-review screening after clinical and non-clinical information has been collected.
Perform initial screening of precertification requests received from physicians or members through calls or correspondence, using established scripts and workflows under clinical or supervisory oversight.
Assist members with finding providers, resolving problems, and answering questions about obtaining services or filing an appeal.
Make outbound calls to engage members in Case Management and complete health assessments (IHS/HRA, CNA/CMNA, MLTSS Eligibility Survey).
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 PCP or specialists and with transportation; process PCP and demographic changes and requests for new ID cards.
Triage and distribute referrals from Member Services and incoming provider faxes.
For Behavioral Health Clinical Operations only: work one holiday shift per year.
For the Letters Team only: review medical and administrative documentation for accuracy, grammar, and regulatory compliance; perform initial screening of determination letters; and make sound, timely decisions under a designated Supervisor’s direction and supervision.
For Medically Certified Spanish Translators only: review documentation in English and Spanish, translate clinical and non-clinical documents between the languages, and assist with onboarding and training Managed Care Coordinators on language protocols and workflow processes.
Perform other relevant tasks as assigned by management.