Medical Services Coordination Specialist I

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

📋 Description

• Assist in the workflow of the Medical Services division, focusing on Behavioral Health, Quality Management, and Member Care Management programs.

• Review and prepare clinical cases for clinical personnel.

• Evaluate member needs utilizing Health Plan-approved case management guidelines and assessment tools.

• Refer to clinical programs and collaborate with clinical care teams to support enrollees.

• Collaborate with enrollees, caregivers, and legal guardians to establish and achieve shared treatment objectives.

• Manage caseloads and ensure documentation aligns with Health Plan standards.

• Advocate for members, address social determinants of health, offer coaching, and facilitate case/disease management referrals.

• Connect enrollees with community resources to ensure timely appointment referrals.

• Monitor member engagement, follow up on outstanding actions, close care gaps, and complete necessary assessments.

• Engage members via phone, messaging, and digital tools.

• Identify members with care gaps using various information sources, HEDIS quality measures, and Value Based Payment Programs.

• Provide outreach and education on healthcare quality metrics, evaluate barriers to care, and support access or referrals.

• Coordinate access to transportation, pharmacy, grocery, food pantry, and other community resources.

• Prepare and manage member and provider correspondence related to disease conditions and care management services.

• Oversee BH/MCM/Quality inboxes and Stored Information Retrieval queues.

• Comply with service-level agreements, regulatory commitments, and required timeframes.

• Ensure care management referrals are precise and complete through collaboration with internal departments.

• Request medical records, send educational materials, respond to calls and emails, and perform other non-clinical support tasks.

• Conduct intake assessments and triage calls to the appropriate MCM/Quality service area.

• Provide initial support to providers, facilities, and members.

• Communicate with members and service providers in line with regulatory and organizational guidelines.

• Safeguard member privacy, uphold company values, and carry out other assigned tasks.

• Level II: Prioritize tasks, mentor junior staff, assist with training and onboarding, guide staff, troubleshoot inquiries, identify barriers, update procedures, and generate care management statistics.

• Level III: Oversee inventory and workflow, deliver reporting and recommendations, revise policies and procedures, implement process improvements, manage complex issues, assess training needs, identify eligibility and coverage, and collaborate on system/process enhancements.

⛳️ Requirements

• At least one year of experience in an insurance company, as a medical assistant, in Health Plan customer service, in care coordination at a community-based organization, or in a patient-facing medical care environment is required.

• Familiarity with medical terminology.

• Proficient in Microsoft Office Suite.

• Exceptional oral and written communication skills.

• Strong organizational and interpersonal skills; ability to handle multiple tasks under pressure.

• Competence in using department-specific applications and software, including care management systems and department libraries.

• Capability to utilize engagement strategies such as motivational interviewing.

• Attention to detail is essential.

• Level II: Minimum of three years of experience in an insurance company, community-based care coordination organization, or medical care setting is required.

• Level II: Extensive knowledge of complex rules, care management systems and processes, departmental policies and procedures, product lines, and regulatory requirements.

• Level II: Ability to identify sensitive issues and escalate concerns; lead committee activities; support newer team members; exceed productivity standards; identify process improvements; resolve complex issues.

• Level III: Minimum of five years of experience in an insurance company or medical care setting is required.

• Level III: Comprehensive knowledge of health plan contracts, regulatory requirements, and unit procedures.

• Level III: Familiarity with multiple systems and/or processes for identifying and resolving data or process issues.

• Level III: Ability to mentor new staff, tackle complex challenges, work independently, participate in meetings and special projects, identify process efficiencies, and develop implementation plans.

• Level III: Proven presentation skills.

• Ability to work for extended periods sitting and/or standing at a workstation and using a computer.

• Ability to use a keyboard, mouse, and/or phone for three or more hours continuously.

• Willingness to travel across the Health Plan service region for meetings and/or training as necessary.

• Ability to hear, comprehend, and communicate clearly while using a phone.

• Regular and dependable attendance is mandatory.

🏝️ Benefits

• Group health and/or dental insurance.

• Retirement plan.

• Wellness program.

• Paid time off.

• Paid holidays.

• Potential for remote work on a case-by-case basis.

• Opportunity to work from a home office for extended periods for business continuity.

• Equal Opportunity Employer.