Managed Care Coordinator

Horizon Connect @ Wall BCBSNJ

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

Posted 9/15/2026full-timeRemote • Connecticut • United StatesMid-LevelSenior💰 $44,600 - $59,745 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in medical terminology, customer service, and claims processing while effectively communicating with members and providers. Capable of making sound decisions under supervision and managing case-related tasks efficiently.

Highest-signal resume keywords

Medical Terminology KnowledgeCustomer Service ExperienceClaims Coding/Processing KnowledgeGood Oral and Written Communication SkillsStrong Analytical Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ProcessingData CollectionCase ManagementRegulatory Compliance ReviewPre-Certification Screening

Soft Skills

Interpersonal SkillsTeam PlayerProblem-Solving AbilityDecision-Making Under Supervision

Tools & Technologies

Personal ComputerApplicable Software Systems

Industry Keywords

Medicaid Case ManagementManaged Care PrinciplesEnrollmentBillingPreventive Health Activities

About the role

Key responsibilities & impact

Perform review of service requests for completeness, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients.
Prepare, document and route cases in the appropriate system for clinical review.
Initiate callbacks and correspondence to members and providers to coordinate and clarify benefits and case completion.
Review professional medical/claim policy-related issues or claims in pending status.
Act as liaison with providers, members, Care Managers, Physicians, Delegates, Operational Business members and Member Service Coordinators.
Authorize services based on scripts or algorithms used for pre-review screening, under clinical staff oversight.
Handle initial screening for pre-certification requests via incoming calls or correspondence based on scripts and workflows.
Assist members with finding providers, resolving problems, answering questions, filing appeals, and obtaining services.
Make outbound calls to engage members in Case Management and complete health assessments.
Educate members regarding preventive health activities and services.
Assist members with appointments, transportation, PCP and demographic changes, and new ID cards.
Triage and distribute referrals and provider faxes.
Review medical, dental and vision claims and address gaps in preventive care.
Review medical and administrative documentation for accuracy, grammar and regulatory compliance.
Perform initial screening of determination letters before distribution.
Make sound, timely decisions under Supervisor direction and perform other assigned tasks.

Requirements

What you’ll need

High School Diploma/GED required.
Prefer 1-2 years customer service or medical support related position.
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.
Employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware.

Benefits

Comp & perks

Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement