Managed Care Coordinator

Description: Job Summary: 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. The ClientC I - UM Letter Team role is essential to ensuring that all member communications are accurate, compliant, and professionally delivered. Success in this role requires strong attention to detail, the ability to manage time effectively in a remote environment, and the flexibility to adapt and pivot in response to changing priorities.



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. - 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. Review medical and administrative documentation for accuracy, grammar, and compliance with regulatory standards. Perform initial screening of determination letters, ensuring clarity and compliance before distribution. Make sound, timely decisions under the direction and supervision of a designated Supervisor. Perform other relevant tasks as assigned by Management.


Core Individual Contributor Competencies: Personal and professional attributes that are critical to successful performance for Individual Contributors: Customer Focus Accountable Learn Communicate



Qualifications:
Education: - High School Diploma required. Some College preferred.



Work experience:
Prefer 3-5 years customer service or medical support related position.
Specialized knowledge/skills:
Requires knowledge of medical terminology - 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 Requires knowledge of clinical standards of care, and Star measures.
Requires operational knowledge of health care delivery systems and health insurance industry. Requires appreciation for strategic planning.
Requires knowledge of NCQA accreditation standards as well as state and federal laws applicable to health plan appeals and grievances.
Requires knowledge of CMS and state regulatory requirements.
Requires knowledge of Microsoft 365 and Adobe Pro.