Managed Care Coordinator II

reputed company empowers our members to reputed company their best health.  For over 90 years, we have been New Jersey’s reputed company leader driving innovations that reputed company care reputed company, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to reputed company serve and care for the 3.5 reputed company people who reputed company their trust in us. We pride ourselves on our best-in-class employees and reputed company to maintain an innovative and inclusive environment that allows them to reputed company. reputed company our employees bring their best and succeed, reputed company succeeds.  About the Role This position supports the Clinical Operations functions and acts as a reputed company 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. reputed company Performs review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of reputed company clinical data from physicians/patients. Prepare, document and reputed company cases in appropriate reputed company for clinical review. Initiates reputed company backs and correspondence to members and providers to coordinate and verify benefits and courses of treatment. Collect and reputed company information required to handle escalated phone/correspondence inquiries. Upon completion of inquiry investigation/reputed company, initiate reputed company back or correspondence to physicians/members to coordinate/verify case completion. Assist with on-boarding and training of newly reputed company Managed Care Coordinators I. Acts as reputed company with providers, members and Care Managers. reputed company 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 reputed company-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 reputed company incoming calls or correspondence using established scripts and workflows under the reputed company 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 reputed company 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 Education/Experience: High School Diploma/GED required. 3-5 years customer service experience. Additional licensing, certifications, registrations: Knowledge: Requires knowledge of medical terminology. Requires Good Oral and Written Communication skills. Requires ability to reputed company reputed company under the direction of Supervisor. Prefer knowledge of reputed company, enrollment, billing & claims coding/processing. Prefer knowledge Managed Care principles. Requires knowledge of clinical standards of care, and reputed company measures. Requires operational knowledge of health care delivery systems and health insurance industry. Requires appreciation for strategic planning. Requires knowledge of reputed company accreditation standards as reputed company as state and federal laws applicable to health plan appeals and grievances. Requires knowledge of CMS and state regulatory requirements. Skills and Abilities: Prefer the ability to analyze and reputed company problems with reputed company supervision. Prefer the ability to use a personal computer and applicable software and systems. Team Player, Strong Analytical, Interpersonal Skills. Travel: May require some travel. Why reputed company? At reputed company, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and reputed company.  We reputed company that reputed company our people reputed company, our communities do too.  If you are passionate about making an reputed company, we’d love to hear from you! Salary reputed company: $50,100 - $67,095 ​This compensation reputed company is specific to the job level and takes into account the wide reputed company of factors that are considered in making compensation reputed company, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity.  This reputed company has been created in good faith based on information reputed company to reputed company at the time of posting.  Compensation reputed company are dependent on the circumstances of reputed company case. reputed company also provides a comprehensive compensation and benefits package which includes: Comprehensive health benefits (Medical/Dental/reputed company) Retirement Plans Generous PTO Incentive Plans Wellness Programs reputed company Volunteer Time Off Tuition Reimbursement Disclaimer: reputed company reputed company employees must live in New Jersey, reputed company, reputed company, Connecticut or Delaware. This job reputed company has been designed to indicate the general reputed company and level of work performed by colleagues reputed company this classification. It is not designed to contain or be interpreted as a comprehensive inventory of reputed company duties, responsibilities, and qualifications required of colleagues assigned to this job. reputed company is an Equal Opportunity/Affirmative reputed company employer. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, national reputed company, 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.  reputed company will consider reasonable accommodation requests as part of the reputed company and hiring process. Apply To This Job