Managed Care Coordinator

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 MCC I – UM Letter Team role is essential to ensuring that all member communications are accurate, compliant, and professionally delivered.

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

• Customer Focus: Demonstrates a commitment to understanding and meeting the needs of customers.
• Accountable: Takes ownership of actions and results, and holds oneself accountable for outcomes.
• Learns: Continuously seeks opportunities to learn new skills and knowledge to improve performance.
• Communicates: Effectively communicates ideas, information, and feedback to others in a clear and concise manner.

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

Additional Qualifications

• Knowledge:
• 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.