Senior Managed Care & Case Management Coordinator

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 is seeking a role in Clinical Operations to support a non-clinical team, coordinate with members, physicians, delegates and Care Managers, and handle escalated issues. The position emphasizes translation between English and Spanish and onboarding new staff.

You will engage in utilization management and case management activities, review medical and administrative documents for accuracy, and contribute to the overall efficiency of member services in a

Qualifications

• High School Diploma or GED required.
• 3-5 years customer service experience.
• Knowledge of medical terminology.
• Excellent oral and written communication.
• Ability to make sound decisions under supervision.
• Knowledge of contracts, enrollment, billing & claims coding/processing.
• Knowledge of Managed Care principles.
• Knowledge of clinical standards of care and Star measures.
• Knowledge of NCQA accreditation standards and applicable laws.
• Knowledge of CMS and state regulatory requirements.
• Spanish translation capability for clinical/non-clinical documents.

Responsibilities

• Review service requests for completeness and collect non-clinical data.
• Prepare and route cases for clinical review.
• Coordinate benefits and treatment through calls to members and providers.
• Handle escalated inquiries and coordinate case information.
• Onboard and train new Managed Care Coordinators I.
• Liaise with providers, members and Care Managers.
• Translate documents between English and Spanish as needed.
• Support case management and utilization management processes.

Skills

Problem solving

PC/computer skills

Team player

Analytical skills

Interpersonal skills

Spanish translation (context)

Education

High School Diploma/GED

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking a role in Clinical Operations to support a non-clinical team, coordinate with members, physicians, delegates and Care Managers, and handle escalated issues. The position emphasizes translation between English and Spanish and onboarding new staff.

You will engage in utilization management and case management activities, review medical and administrative documents for accuracy, and contribute to the overall efficiency of member services in a