Managed Care Coordinator I

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

📋 Description

• Assists the Clinical Operations team and serves as a bridge between Members, Physicians, Delegates, Operational Business personnel, and Member Service Coordinators.

• Conducts reviews of service requests to ensure information completeness, gathers and transfers non-clinical data, and obtains structured clinical data from physicians and patients.

• Prepares, documents, and submits cases in the designated system for clinical evaluation.

• Initiates callbacks and correspondence with members and providers to coordinate and clarify benefits and case finalization.

• Evaluates professional medical/claim policy-related matters or claims that are currently pending.

• Acts as a liaison among providers, members, and Care Managers.

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

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

• Aids members in locating providers, resolving issues, and answering inquiries about acquiring services and filing appeals.

• Makes outbound calls to involve members in Case Management and complete health assessments.

• Informs members about preventive health activities and services.

• Assists members with scheduling appointments, arranging transportation, updating PCP and demographic information, and issuing new ID cards.

• Triages and distributes referrals and provider faxes.

• Reviews medical, dental, and vision claims, addressing deficiencies in members' preventive care.

• Performs additional relevant tasks as assigned by Management.

⛳️ Requirements

• High School Diploma/GED is mandatory.

• Preference for candidates with 1-2 years of experience in customer service or a medical support-related role.

• Knowledge of medical terminology is required; familiarity with Medicaid CM is preferred.

• Strong oral and written communication skills are essential.

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

• Preference for 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 and 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 (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement