Managed Care Coordinator
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POST DATE 8/25/2016
END DATE 10/15/2016
Horizon Blue Cross Blue Shield of New Jersey
JOB DESCRIPTIONJob Summary:
This position supports the Health Services and Utilization Management 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.
* Handles initial screening for pre-certification requests from physicians/members via incoming calls or correspondence based on scripts and workflows, and under the oversight of clinical staff.
* 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.
* Upon completion of inquiries initiate call back or correspondence to Physicians/Members to coordinate/clarify case completion.
* Reviewing professional medical/claim policy related issues or claims in pending status.
* Upon collection of clinical and non-clinical information MCC can authorize services based upon scripts or algorithms used for pre-review screening.
* Non Clinical staff members are not responsible for conducting any UM review activities that require interpretation of clinical information.
* Perform other relevant tasks as assigned by Management.
* High School Diploma required. Some College preferred.
* Prefer 1-2 years customer service or medical support related position.
* Requires knowledge of medical terminology.
* 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.
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.
High School Diploma, GED
--Horizon NJ Health