Managed Care Coordinator I

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

📋 Description

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

• Prepares, documents, and routes cases in the appropriate system for clinical evaluation.

• Initiates callbacks and correspondence with members and providers to coordinate and clarify benefits and complete cases.

• Evaluates professional medical or claim policy-related issues or claims that are in pending status.

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

• 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 from physicians or members through incoming calls or correspondence, based on established scripts and workflows.

• Assists members in locating providers, resolving issues, and answering inquiries regarding service acquisition and appeal filing.

• Makes outbound calls to engage members in Case Management and conduct health assessments.

• Educates members on preventive health activities and available services.

• Aids members with appointment scheduling, transportation, changes to primary care providers and demographics, and issuance of new ID cards.

• Triages and routes referrals from Member Services and incoming provider faxes.

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

• Executes other relevant tasks as assigned by Management.

⛳️ Requirements

• High School Diploma or GED is required.

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

• Requires familiarity with medical terminology.

• Preferred experience in Medicaid Case Management.

• Requires strong oral and written communication skills.

• Must be capable of making sound decisions under the direction of a Supervisor.

• Preferably knowledgeable in contracts, enrollment, billing, and claims coding/processing.

• Prefer knowledge of Managed Care principles.

• Prefer the ability to analyze and resolve issues with minimal supervision.

• Prefer proficiency in using a personal computer and relevant software and systems.

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

🏝️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision).

• Retirement Plans.

• Generous PTO.

• Incentive Plans.

• Wellness Programs.

• Paid Volunteer Time Off.

• Tuition Reimbursement.