Managed Care Coordinator

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

3d • Onsite

About The Position

This position supports the Health Services and Utilization Management functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators. The role involves reviewing service requests, handling initial screening for pre-certification requests, preparing and routing cases for clinical review, and initiating communication with members and providers to coordinate and clarify benefits and case completion. Non-clinical staff are not responsible for interpreting clinical information during UM review activities.

Requirements

• High School Diploma 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

• Some College preferred.
• Prefer 1-2 years customer service or medical support related position.
• 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.
• 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.
• 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.
• Upon collection of clinical and non-clinical information ClientC 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.
• Perform other relevant tasks as assigned by Management.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED