Managed Care Coordinator II (Bilingual - Spanish)

Horizon-Blue-Cross-Blue-Shield-of-New-Jersey; Hopewell (NJ); On-site; USD 50,000 - 67,000; Full time

Benefits offered by this job

Comprehensive health benefits

Retirement plans

Generous PTO

Incentive plans

Wellness programs

Paid volunteer time off

Tuition reimbursement

Job summary

Horizon Blue Cross Blue Shield of New Jersey seeks a Managed Care Coordinator to support Clinical Operations, acting as a liaison between members, physicians, delegates, and Care Managers. You will review service requests, collect data, and coordinate benefits and care with providers.

You will also assist with onboarding of new Coordinators, participate in UM/CM activities, and translate documents as needed, ensuring clear communication and efficient case resolution.

Qualifications

• 3-5 years customer service experience.
• Knowledge of medical terminology and health insurance basics.
• Ability to translate clinical content between English and Spanish.

Responsibilities

• Review service requests for completeness and collect data.
• Coordinate benefits and treatment with members and providers.
• Assist onboarding and training of new Managed Care Coordinators.
• Educate members on preventive health activities and scheduling appointments.
• Translate clinical and non-clinical documents between English and Spanish.

Skills

Strong analytical

Interpersonal skills

Team player

Education

High School Diploma/GED

Medical translator certification

Job description

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.About the RoleThis 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.What You'll DoPerforms 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 in order 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 yearReview 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.What You BringEducation/Experience:High School Diploma/GED required.3-5 years customer service experience.Additional licensing, certifications, registrations:Medical certification translator education (Letter’s Team, Medically Certified Spanish Translator only).Knowledge:Requires knowledge of medical terminologyRequires Good Oral and Written Communication skillsRequires ability to make sound decisions under the direction of SupervisorPrefer knowledge of contracts, enrollment, billing & claims coding/processingPrefer knowledge Managed Care principlesRequires 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. (Letters Team, Medically Certified Spanish Translator)Requires knowledge of CMS and state regulatory requirements. (Letters Team, Medically Certified Spanish Translator only)Skills and Abilities:Prefer the ability to analyze and resolve problems with minimal supervisionPrefer the ability to use a personal computer and applicable software and systemsTeam Player, Strong Analytical, Interpersonal SkillsTravel:May require some travel.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:$50,100 - $67,095This 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. Horizon also provides a comprehensive compensation and benefits package which includes:Comprehensive health benefits (Medical/Dental/Vision)Retirement PlansGenerous PTOIncentive PlansWellness ProgramsPaid Volunteer Time OffTuition ReimbursementDisclaimer: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, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.