Care Coordinator

• 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.
• 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 when appropriate.
• Handles initial screening for pre-certification requests under the oversight of clinical staff.
• Assists members with finding providers, resolving problems and answering questions regarding services and appeals.
• Makes outbound calls to engage members in Case Management and complete necessary 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 preventive care.
• Reviews medical and administrative documentation for accuracy, grammar, and regulatory compliance.
• Performs initial screening of determination letters before distribution.
• Makes sound, timely decisions under the direction and supervision of a designated Supervisor.
• Performs other relevant tasks as assigned by Management.

Explore Managed Care Coordinator I, Behavioral Health at Horizon Connect @ Wall BCBSNJ. Review requirements and application details.