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H
Managed Care Coordinator II
Horizon Connect @ Wall BCBSNJ. Review service requests for completeness and collect, transfer, and acquire non-clinical and structured clinical data .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in managing non-clinical and structured clinical data, coordinating with healthcare providers, and ensuring compliance with clinical standards and regulations. Proficient in customer service, communication, and problem-solving within the healthcare delivery system.
Highest-signal resume keywords
Customer Service ExperienceMedical Terminology KnowledgeClinical Standards of Care KnowledgeNCQA Accreditation Standards KnowledgeBilingual Communication (English and Spanish)
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Data CollectionCase ManagementPrecertification Request ScreeningHealth AssessmentsClaims ReviewOperational Knowledge of Health Care Delivery SystemsRegulatory Compliance KnowledgeDecision-Making Under SupervisionReferral TriageDocument Translation
Soft Skills
Analytical SkillsInterpersonal SkillsCommunication SkillsTeam CollaborationProblem-Solving
Certifications & Qualifications
Medical Certification Translator Education
Industry Keywords
Health Insurance IndustryCMS Regulatory RequirementsState and Federal LawsStar MeasuresHealth Plan Appeals and Grievances
About the role
Key responsibilities & impact- Review service requests for completeness and collect, transfer, and acquire non-clinical and structured clinical data
- Prepare, document, and route cases for clinical review
- Contact members and providers to coordinate and verify benefits, treatment courses, and case completion
- Investigate and resolve escalated phone and correspondence inquiries
- Assist with onboarding and training newly hired Managed Care Coordinators I
- Act as liaison with providers, members, Care Managers, physicians, delegates, operational business members, and member service coordinators
- Authorize services based on scripts or algorithms for pre-review screening under clinical oversight
- Perform initial screening of precertification requests using established scripts and workflows
- Help members find providers, resolve problems, and understand services and appeals
- Engage members in Case Management and complete health assessments
- Distribute case assignments to Case Management Clinical Staff
- Review medical, dental, and vision claims and address preventive-care gaps
- Educate members about preventive health activities and services
- Assist with appointments, transportation, PCP and demographic changes, and new ID cards
- Triage and distribute referrals and provider faxes
- Review and translate English and Spanish medical and administrative documents for designated teams
- Work one holiday shift per year for Behavioral Health Clinical Operations
Requirements
What you’ll need- High School Diploma/GED required
- 3-5 years customer service experience
- Medical certification translator education required for Letter’s Team and Medically Certified Spanish Translator roles
- Knowledge of medical terminology
- Good oral and written communication skills
- Ability to make sound decisions under the direction of a Supervisor
- Knowledge of clinical standards of care and Star measures
- Operational knowledge of health care delivery systems and the health insurance industry
- Knowledge of NCQA accreditation standards and applicable state and federal laws for health plan appeals and grievances (Letter’s Team and Medically Certified Spanish Translator)
- Knowledge of CMS and state regulatory requirements (Letter’s Team and Medically Certified Spanish Translator only)
- Team player with strong analytical and interpersonal skills
- May require some travel
- 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
- Meaningful work that directly improves lives
- Mission-driven organization supporting expertise, collaboration, and growth