Managed Care Coordinator II: Case Management & Member Support

Horizon Blue Cross Blue Shield of New Jersey; United States; Remote; USD 50,000 - 67,000; Full time

Benefits offered by this job

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 is seeking a Clinical Operations liaison to support non-clinical teams and handle escalated issues. You will review service requests, coordinate benefits, and assist with onboarding of new staff, while acting as a liaison with providers, members and Care Managers.

Responsibilities include UM screening, case management support, and maintaining regulatory compliance across health plan processes. Travel may be required.

Qualifications

• High School Diploma/GED required.
• 3-5 years customer service experience.
• Medical certification translator education (Letter’s Team, Medically Certified Spanish Translator only).
• 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.
• Requires knowledge of clinical standards of care, and Star measures.
• 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)

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.
• 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.
• 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.
• 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.
• 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.

Skills

Analytical skills

Problem solving

Team player

Education

High School Diploma/GED

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking a Clinical Operations liaison to support non-clinical teams and handle escalated issues. You will review service requests, coordinate benefits, and assist with onboarding of new staff, while acting as a liaison with providers, members and Care Managers.

Responsibilities include UM screening, case management support, and maintaining regulatory compliance across health plan processes. Travel may be required.