Managed Care Coordinator I

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years , we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.
About the Role
This position supports the Clinical Operations functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators What You'll Do

-
Performs review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients.

-
Prepare, document and route cases in appropriate system for clinical review. Initiates call backs and correspondence to members and providers to coordinate and clarify benefits.

-
Upon completion of inquiries initiate call back or correspondence to Physicians/Members to coordinate/clarify case completion.

-
Reviewing professional medical/claim policy related issues or claims in pending status.

-
Acts as liaison with providers, members and Care Managers.

-
Perform other relevant tasks as assigned by Management.

Utilization Management:

-
Upon collection of clinical and non-clinical information MCC can authorize services based upon scripts or algorithms used for pre-review screening.

-
Non Clinical staff members are not responsible for conducting any UM review activities that require interpretation of clinical information.

-
Handles initial screening for pre-certification requests from physicians/members via incoming calls or correspondence based on scripts and workflows, and under the oversight of clinical staff.

Case Management:

-
Assists members with finding providers, resolving problems and answering questions regarding anything from how to obtain services to how to file an appeal.

-
Makes outbound calls to in order to engage members in Case Management and to complete the necessary health assessment(s) (IHS/HRA, CNA/CMNA, MLTSS Elig Survey*.)

-
Educates members regarding preventive health activities and services.

-
Assists member to make appointments with their PCP, specialists, and/or transportation, etc. Handle PCP, demographic changes and/or new ID cards as requested by members.

-
Triage and distribute referrals from Member Services and incoming faxes from providers.

-
Reviews medical, dental and vision claims and address gaps in member's preventative care.

Letters Team:

-
Review medical and administrative documentation for accuracy, grammar, and compliance with regulatory standards.

-
Perform initial screening of determination letters, ensuring clarity and compliance before distribution.

-
Make sound, timely decisions under the direction and supervision of a designated Supervisor.

What You Bring
Education/Experience:

- High School Diploma/GED required.

-
Prefer 1-2 years customer service or medical support related position.

Knowledge and Skills:

-
Requires knowledge of medical terminology, Preferred – Medicaid CM.

-
Requires Good Oral and Written Communication skills.

-
Requires ability to make sound decisions under the direction of Supervisor.

-
Prefer knowledge of contracts, enrollment, billing & claims coding/processing.

-
Prefer knowledge Managed Care principles.

-
Prefer the ability to analyze and resolve problems with minimal supervision.

-
Prefer the ability to use a personal computer and applicable software and systems.

-
Team Player, Strong Analytical, Interpersonal Skills.

Why Horizon?

At Horizon, you’ll do mea