Managed Care Coordinator

This is a fully remote position, open to applicants in Connecticut, +3 more states.

📋 Description

• Conduct reviews of service requests to ensure completeness, gather and transfer non-clinical data, and obtain structured clinical data from physicians and patients.

• Prepare, document, and route cases in the designated system for clinical evaluation.

• Initiate callbacks and correspondence with members and providers to coordinate and clarify benefits and ensure case completion.

• Review professional medical and claim policy-related issues or claims that are currently pending.

• Serve as a liaison among providers, members, Care Managers, Physicians, Delegates, Operational Business personnel, and Member Service Coordinators.

• Authorize services based on scripts or algorithms utilized for pre-review screening, under the oversight of clinical staff.

• Conduct initial screenings for pre-certification requests through incoming calls or correspondence, adhering to scripts and workflows.

• Assist members in locating providers, resolving issues, answering inquiries, filing appeals, and obtaining necessary services.

• Make outbound calls to engage members in Case Management and complete health assessments.

• Educate members about preventive health activities and available services.

• Assist members with scheduling appointments, arranging transportation, making changes to their primary care physician (PCP) and demographics, and issuing new ID cards.

• Triage and distribute referrals and faxes from providers.

• Evaluate medical, dental, and vision claims while addressing gaps in preventive care.

• Review medical and administrative documentation for accuracy, grammar, and compliance with regulations.

• Conduct an initial screening of determination letters prior to distribution.

• Make informed, timely decisions under the direction of a Supervisor and perform additional assigned tasks.

⛳️ Requirements

• High School Diploma or GED is required.

• Preferred experience of 1-2 years in a customer service or medical support role.

• Must have a solid understanding of medical terminology.

• Preferred experience with Medicaid Case Management.

• Strong oral and written communication skills are essential.

• Ability to make sound decisions under the guidance of a Supervisor is required.

• Preferred knowledge of contracts, enrollment, billing, and claims coding/processing.

• Understanding of Managed Care principles is preferred.

• Ability to analyze and resolve issues with minimal supervision is preferred.

• Proficiency in using a personal computer along with relevant software and systems is preferred.

• Must be a team player with strong analytical and interpersonal skills.

• Employees must reside in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

🏝️ Benefits

• Comprehensive health benefits including Medical, Dental, and Vision.

• Retirement Plans.

• Generous Paid Time Off (PTO).

• Incentive Plans.

• Wellness Programs.

• Paid Volunteer Time Off.

• Tuition Reimbursement.