Managed Care Coordinator II

This is a fully remote position, open to applicants in New Jersey.

📋 Description

• Provide support for Clinical Operations activities and serve as a liaison among members, physicians, delegates, and member service coordinators.

• Offer leadership and direction to the non-clinical team while managing escalated issues and challenges.

• Review service requests to ensure all information is complete.

• Gather and transfer non-clinical and structured clinical data from both physicians and patients.

• Initiate follow-up calls and correspondence with members and providers to verify and coordinate benefits.

• Collect and organize information necessary for addressing escalated inquiries via phone or correspondence.

• Assist in the onboarding and training processes for new Managed Care Coordinators I.

• Conduct initial screenings of precertification requests from physicians or members, following established scripts.

• Help members locate providers, resolve issues, and answer their queries.

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

• Assign new cases to the Case Management Clinical Staff.

• Review medical, dental, and vision claims, addressing any gaps in preventive care for members.

⛳️ Requirements

• A High School Diploma or GED is mandatory.

• 3-5 years of experience in customer service is required.

• Familiarity with medical terminology is essential.

• Strong oral and written communication skills are necessary.

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

• Knowledge of contracts, enrollment, billing, and claims coding/processing is preferred.

• Understanding of Managed Care principles is preferred.

• Familiarity with clinical standards of care and Star measures is necessary.

• Operational knowledge of healthcare delivery systems and the health insurance industry is required.

• Appreciation for strategic planning is necessary.

• Knowledge of NCQA accreditation standards is required.

• Understanding of CMS and state regulatory requirements is necessary.

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

• Proficiency in using personal computers and relevant software and systems is preferred.

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

• Some travel may be required.

🏝️ 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.