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H
Managed Care Coordinator I
Horizon Connect @ Wall BCBSNJ. Supports the Clinical Operations functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical operations support, including effective communication with members and providers, and proficiency in managing service requests and claims processing. Strong analytical skills and knowledge of medical terminology are essential for problem-solving and decision-making in a healthcare environment.
Highest-signal resume keywords
Medical Terminology KnowledgeCustomer Service ExperienceClaims Coding/Processing KnowledgeStrong Analytical SkillsGood Oral And Written Communication Skills
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 ProcessingService Request ReviewPre-Certification ScreeningData CollectionReferral TriageHealth Assessment CoordinationPreventive Health EducationProblem ResolutionDecision MakingMedical Claim Review
Soft Skills
Interpersonal SkillsTeam PlayerCommunication SkillsAnalytical SkillsProblem-Solving Skills
Tools & Technologies
Personal ComputerApplicable Software Systems
Industry Keywords
Managed Care PrinciplesMedicaid CMHealthcare OperationsMember ServicesClinical Review
About the role
Key responsibilities & impact- Supports the Clinical Operations functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators.
- 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 and Care Managers.
- Authorizes services based upon scripts or algorithms used for pre-review screening under the oversight of clinical staff.
- Handles initial screening for pre-certification requests 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 and 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.
- 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