Managed Care Coordinator I

Managed Care Coordinator I

Requirements

• High School Diploma/GED required.
• 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.

Responsibilities

• 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.
• 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.
• Acts as liaison with providers, members and Care Managers.
• Perform other relevant tasks as assigned by Management.
• 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.
• 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*).
• Educates members regarding preventive health activities and services.
• Assists member to make appointments with their PCP, specialists, and/or transportation, etc. Handle PCP, demographic changes and/or new ID cards as requested by members.
• Triage and distribute referrals from Member Services and incoming faxes from providers.
• Reviews medical, dental and vision claims and address gaps in member’s preventative care.

Preferred Qualifications

• Preferred – Medicaid CM.
• 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.