[Hiring] Managed Care Coordinator I @Horizon Blue Cross Blue Shield of New Jersey

Role Description

This position supports the Clinical Operations functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators.

• 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.

Utilization Management:

• Upon collection of clinical and non-clinical information, MCC 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.
• 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.

Case Management:

• 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 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.
• Handles 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.

Qualifications

• High School Diploma/GED required.
• Prefer 1-2 years customer service or medical support related position.

Requirements

• Requires knowledge of medical terminology.
• Preferred – Medicaid CM.
• Requires Good Oral and Written Communication skills.
• Requires ability to make sound decisions under the direction of Supervisor.
• 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.

Benefits

• Comprehensive health benefits (Medical/Dental/Vision)
• Retirement Plans
• Generous PTO
• Incentive Plans
• Wellness Programs
• Paid Volunteer Time Off
• Tuition Reimbursement