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H
Managed Care Coordinator I
Horizon Connect @ Wall BCBSNJ. 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 .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical terminology and customer service within a healthcare environment, effectively coordinating with members and providers to facilitate case management and claims processing.
Highest-signal resume keywords
Medical Terminology KnowledgeCustomer Service ExperienceClaims Coding/Processing KnowledgeGood Oral and Written Communication SkillsAnalytical Problem-Solving
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims ProcessingPre-Certification ScreeningData CollectionCase ManagementMedical Claims Review
Soft Skills
Interpersonal SkillsTeam PlayerDecision-Making AbilityStrong Analytical Skills
Tools & Technologies
Personal ComputerApplicable Software Systems
Certifications & Qualifications
High School Diploma/GED
Industry Keywords
Managed Care PrinciplesMedicaid Case ManagementEnrollmentBillingPreventive Health Activities
About the role
Key responsibilities & impact- 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
- Prepares, documents and routes cases in the appropriate system for clinical review
- Initiates callbacks and correspondence to members and providers to coordinate and clarify benefits and case completion
- Reviews professional medical/claim policy-related issues or claims in pending status
- Acts as liaison with providers, members, Care Managers, Physicians, Delegates, Operational Business members and Member Service Coordinators
- Authorizes services based upon scripts or algorithms used for pre-review screening under clinical staff oversight
- Handles initial screening for pre-certification requests from physicians/members via incoming calls or correspondence based on scripts and workflows
- Assists members with finding providers, resolving problems and answering questions about obtaining services and filing appeals
- Makes outbound calls to engage members in Case Management and complete health assessments
- Educates members regarding preventive health activities and services
- Assists members with appointments, transportation, PCP and demographic changes, and new ID cards
- Triages and distributes referrals from Member Services and incoming provider faxes
- Reviews medical, dental and vision claims and addresses gaps in members' preventive care
- Performs other relevant tasks as assigned by Management
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
Benefits
Comp & perks- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement