Job Details

  • Title: Managed Care Coordinator
  • Code: RCI-7957-1
  • Location: Newark New Jersey (NJ) 07105
  • Posted Date: 03/25/2021
  • Duration: 6 Months

  Job Description

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.

Responsibilities:

  • 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.
  • 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.
  • Must be able to navigate through applications and be comfortable working with computers
  • Non Clinical staff members are not responsible for conducting any UM review activities that require interpretation of clinical information.
  • Reviewing professional medical/claim policy related issues or claims in pending status.
  • 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.
  • Upon collection of clinical and non-clinical information MCC can authorize services based upon scripts or algorithms used for pre-review screening.
  • Perform other relevant tasks as assigned by Management.
Qualifications:

  • MCC for inpatient calls, connect with provider, check eligibility and benefits, reviews
  • Being on phone, setting for rehabilitation
  • Medical Management tools : Caradious, NAS, CPL, TPS
  • Education: High School Diploma required. Some College preferred.
  • Prefer 1-2 years customer service or medical support related position.
  • Prefer the ability to use a personal computer and applicable software and systems
  • Prefer knowledge Managed Care principles
  • Requires ability to make sound decisions under the direction of Supervisor
  • Requires knowledge of medical terminology
  • Prefer knowledge of contracts, enrollment, billing & claims coding/processing