[Hiring] Managed Care Coordinator II @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. Responsible for providing leadership and guidance to non-clinical team and handle escalated issues/problems.

• 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.

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 is not responsible for conducting any UM review activities that require interpretation of clinical information.
• 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.

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*).
• 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.
• Review medical and administrative documentation for accuracy, grammar, and compliance with regulatory standards.
• Perform initial screening of determination letters, ensuring clarity and compliance before distribution.
• Make sound, timely decisions under the direction and supervision of a designated Supervisor.
• Review medical and administrative documentation for accuracy, grammar, and compliance with regulatory standards in both English and Spanish.
• Translate clinical and non-clinical documents between English and Spanish, ensuring precise medical terminology and context.
• Assist in the onboarding and training of new Managed Care Coordinators, providing guidance on language protocols and workflow processes.

Qualifications

• High School Diploma/GED required.
• 3-5 years customer service experience.
• Medical certification translator education (Letter’s Team, Medically Certified Spanish Translator only).

Requirements

• Requires knowledge of medical terminology.
• 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 of Managed Care principles.
• 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.
• Requires knowledge of NCQA accreditation standards as well as state and federal laws applicable to health plan appeals and grievances.
• Requires knowledge of CMS and state regulatory requirements.

Skills and Abilities

• 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.

Travel

• May require some travel.

Benefits

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

Salary Range

$50,100 - $67,095