Managed Care Coordinator II

Managed Care Coordinator II

Requirements

• High School Diploma/GED required.
• 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 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.
• Upon collection of clinical and non-clinical information, MCC can authorize services based upon scripts or algorithms used for pre-review screening.
• 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.
• 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.

Preferred Qualifications

• Prefer 3-5 years customer service experience
• 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