Managed Care Coordinator I

Job Description:

This position supports the Clinical Operations functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators

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.

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 members are not responsible for conducting any UM review activities that require interpretation of clinical information.

• 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.

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*.)

• 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.

Education/Experience:

• High School Diploma/GED required.

• Prefer 1-2 years customer service or medical support related position.

Knowledge and Skills:

• Requires knowledge of medical terminology, Preferred – Medicaid CM.

• Requires Good Oral and Written Communication skills.

• Requires ability to make sound decisions under the direction of Supervisor.

• 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.