Managed Care Coordinator in Trenton, NJ

Supplemental help for Appeals Analyst out on STD

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:

• 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.
• 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.
• 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.
• Prefer 1-2 years customer service or medical support related position. 
• Requires knowledge of medical terminology
• Prefer knowledge of contracts, enrollment, billing & claims coding/processing
• Prefer knowledge Managed Care principles

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