Managed Care Coordinator I

100 Horizon Healthcare Services, Inc; Hopewell (NJ); On-site; USD 45,000 - 60,000; Full time

Benefits offered by this job

Comprehensive health benefits (Medical

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Job summary

Horizon BCBSNJ in New Jersey is seeking a role that supports Clinical Operations and acts as a liaison between Members, Physicians, Delegates, and Care Managers.

You will review service requests, prepare cases for clinical review, and coordinate benefits with members and providers. The position emphasizes medical terminology knowledge, good communication, and the ability to work under supervision, with benefits and compensation aligned to the job level.

Qualifications

• Requires High School Diploma or GED.
• Prefer 1-2 years in customer service or medical support.
• Knowledge of medical terminology.
• Excellent oral and written communication.
• Ability to make sound decisions under supervision.

Responsibilities

• Review service requests for completeness and collect data.
• Prepare and route cases for clinical review.
• Coordinate and clarify benefits via calls and correspondence.
• Assist case management and provider/member inquiries.
• Initial screening for pre-certification requests.
• Refer to care managers and providers as needed.
• Educate members on preventive health activities.
• Assist with scheduling appointments and PCP referrals.
• Handle demographics changes and new ID cards.
• Review medical, dental, and vision claims to identify gaps.

Skills

Customer service

Medical terminology

Communication skills

Analytical skills

Team player

Education

High School Diploma/GED

Job description

About the Role

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

What You'll Do

• 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 in order 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.
• Handle 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.

What You Bring

• Education/Experience: High School Diploma/GED required.
• Prefer 1-2 years customer service or medical support related position.
• Knowledge and Skills: 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.

Why Horizon?

At Horizon, you'll do meaningful work that directly improves lives--while being supported by a mission-driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we'd love to hear from you!

Salary Range

Salary Range: $44,600 - $59,745

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case.

Benefits Package

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

Disclaimer

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware.

This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity or status as an individual with a disability and any other protected class as required.

Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

About Us

We are the leading health insurer in New Jersey, trusted by generations of families and businesses. We are dedicated to enriching the lives and health of our members and the New Jersey communities we serve, because we live and work here too.

Our Mission

We empower our members to achieve their best health.

Our Vision

We are New Jersey’s health solutions leader driving innovations that improve health care quality, affordability and member experience in the markets we serve.