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 all necessary information is complete, collects and transfers non-clinical data, and obtains structured clinical data from healthcare providers 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 ensure case completion.

• Reviews issues related to professional medical policies or claims that are currently pending.

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

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

• Conducts initial screenings for pre-certification requests following specific scripts and workflows.

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

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

• Educates members on preventive health activities and services.

• Aids members with appointments, transportation, changes to their primary care provider and demographics, as well as issuing new ID cards.

• Triages and distributes referrals and provider faxes effectively.

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

• Performs other relevant tasks as assigned by Management.

⛳️ Requirements

• High School Diploma or GED is required.

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

• Knowledge of medical terminology is required; experience with Medicaid Case Management is preferred.

• Strong oral and written communication skills are necessary.

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

• Familiarity with contracts, enrollment, billing, and claims coding/processing is preferred.

• Knowledge 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 possess strong analytical and interpersonal skills, and be a team player.

• Horizon BCBSNJ employees are required to reside in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

🏝️ Benefits

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

• Retirement Plans.

• Generous Paid Time Off (PTO).

• Incentive Plans.

• Wellness Programs.

• Paid Volunteer Time Off.

• Tuition Reimbursement.