Managed Care Coordinator II

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. 

About the Role

Job Description Summary
This position supports the Clinical Operations functions and acts as a liaison between members, physicians, delegates, operational business members and member service coordinators. Responsible for providing leadership and guidance to non-clinical team and handle escalated issues/problems.

What You'll Do

• 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 verify benefits and courses of treatment.

• Collect and collate information required to handle escalated phone/correspondence inquiries.

• Upon completion of inquiry investigation/resolution, initiate call back or correspondence to physicians/members to coordinate/verify case completion.

• Assist with on-boarding and training of newly hired Managed Care Coordinators I.

• Acts as liaison with providers, members and Care Managers.

• Perform other relevant tasks as assigned by management.

Utilization Management:

• 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 is not responsible for conducting any UM review activities that require interpretation of clinical information.

• Performs initial screening of precertification requests from physicians/members received via incoming calls or correspondence using established scripts and workflows under the oversight of clinical /supervisory staff.

Case Management:

• Assists members with finding providers, resolving problems and answering questions regarding anything from how to obtain services to how to file an appeal.

• Makes outbound calls to in order to engage members in Case Management and to complete the necessary health assessment(s) (IHS/HRA, CNA/CMNA, MLTSS Elig Survey*).

• Distributes new case assignments to the Case Management Clinical Staff.

• Reviews medical, dental and vision claims and address gaps in member's preventative care.

• Educates members regarding preventive health activities and services.

• Assists members making appointments with their PCP, specialists, and/or transportation, etc. Process PCP, demographic changes and new ID cards as requested by members.

• Triage and distribute referrals from Member Services and incoming faxes from providers.

What You Bring