Managed Care Coordinator I
Horizon Blue Cross Blue Shield of New Jersey · Hopewell, NJ · 1 mo ago
Healthcare$45k–$60k/yrFull-time
We need to output HTML fragment with headings for sections: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Only include sections that have real specific content. We must not repeat job title. Remove boilerplate, navigation, EEO, etc. Keep substantive info.
We need to parse the posting.
Let's extract sections:
- About The Role: "This position supports the Clinical Operations functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators"
- What You'll Do: list of duties. We'll put under Responsibilities.
- Utilization Management: details about screening, etc.
- Case Management: details.
- Letters Team: details.
- Education/Experience: "What You Bring" includes High School Diploma/GED required, Prefer 1-2 years customer service or medical support related position.
- Knowledge And Skills: list of knowledge/skills.
- Why Horizon?: maybe not needed; could be part of Benefits? It's more about culture; but we have Benefits section for actual benefits. The "Why Horizon?" is more about mission; could be omitted or maybe put under Benefits? But we only include sections with real specific content. The "Why Horizon?" is not a standard heading; we could ignore.
- Salary Range: $44,600 - $59,745 plus description. That's Pay.
- Benefits: list: Comprehensive health benefits (Medical/Dental/Vision), Retirement Plans, Generous PTO, Incentive Plans, Wellness Programs, Paid Volunteer Time Off, Tuition Reimbursement.
- Disclaimer about residency: maybe not needed; could be omitted as not a standard section.
- EEO etc: remove.
Thus sections: About the role, Responsibilities, Requirements (maybe Education/Experience), Qualifications (maybe Knowledge And Skills?), Skills (maybe overlapping), Benefits, Pay. Schedule not present, so omit.
We need to avoid duplicate content. Let's map:
About the role: the paragraph.
Responsibilities: combine What You'll Do, Utilization Management, Case Management, Letters Team into a list of duties.
Requirements: Education/Experience (HS diploma/GED, 1-2 years experience).
Qualifications: maybe Knowledge And Skills? But we also have Skills section. Could combine knowledge and skills into Skills. But we need to follow headings: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay.
We can put:
- Requirements: Education/Experience.
- Qualifications: maybe "Preferred – Medicaid CM" etc? Actually Knowledge And Skills includes many items; we could split: Qualifications = knowledge of medical terminology, preferred Medicaid CM, ability to make sound decisions, etc. Skills = interpersonal, team player, analytical, computer use, etc. But we can also just put all under Skills and leave Qualifications empty? But we must not emit empty headings. So we need to decide what goes where.
Better: Use Requirements for education/experience. Use Qualifications for knowledge and skills that are more technical: knowledge of medical terminology, preferred Medicaid CM, knowledge of contracts, enrollment, billing & claims coding/processing, managed care principles, ability to analyze and resolve problems, ability to use PC and software. Use Skills for interpersonal/behavioral: Team Player, Strong Analytical, Interpersonal Skills, Good Oral and Written Communication skills, ability to make sound decisions under supervision (maybe that's more qualification). But we can adjust.
Let's extract:
Knowledge And Skills bullet list (as paragraph):
- 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.
We can split:
Qualifications: knowledge of medical terminology, preferred Medicaid CM, knowledge of contracts, enrollment, billing & claims coding/processing, managed care principles, ability to analyze and resolve problems with minimal supervision, ability to use PC and software.
Skills: Good Oral and Written Communication skills, ability to make sound decisions under direction of Supervisor, Team Player, Strong Analytical, Interpersonal Skills.
But ability to make sound decisions could be qualification; but okay.
Now Responsibilities: combine all duty paragraphs.
Let's list duties from What You'll Do:
- 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 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.
Letters Team:
- 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.
We can combine into a
for sections: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Only include sections that have real specific content. We must not repeat job title. Remove boilerplate, navigation, EEO, etc. Keep substantive info.
We need to parse the posting.
Let's extract sections:
- About The Role: "This position supports the Clinical Operations functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators"
- What You'll Do: list of duties. We'll put under Responsibilities.
- Utilization Management: details about screening, etc.
- Case Management: details.
- Letters Team: details.
- Education/Experience: "What You Bring" includes High School Diploma/GED required, Prefer 1-2 years customer service or medical support related position.
- Knowledge And Skills: list of knowledge/skills.
- Why Horizon?: maybe not needed; could be part of Benefits? It's more about culture; but we have Benefits section for actual benefits. The "Why Horizon?" is more about mission; could be omitted or maybe put under Benefits? But we only include sections with real specific content. The "Why Horizon?" is not a standard heading; we could ignore.
- Salary Range: $44,600 - $59,745 plus description. That's Pay.
- Benefits: list: Comprehensive health benefits (Medical/Dental/Vision), Retirement Plans, Generous PTO, Incentive Plans, Wellness Programs, Paid Volunteer Time Off, Tuition Reimbursement.
- Disclaimer about residency: maybe not needed; could be omitted as not a standard section.
- EEO etc: remove.
Thus sections: About the role, Responsibilities, Requirements (maybe Education/Experience), Qualifications (maybe Knowledge And Skills?), Skills (maybe overlapping), Benefits, Pay. Schedule not present, so omit.
We need to avoid duplicate content. Let's map:
About the role: the paragraph.
Responsibilities: combine What You'll Do, Utilization Management, Case Management, Letters Team into a list of duties.
Requirements: Education/Experience (HS diploma/GED, 1-2 years experience).
Qualifications: maybe Knowledge And Skills? But we also have Skills section. Could combine knowledge and skills into Skills. But we need to follow headings: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay.
We can put:
- Requirements: Education/Experience.
- Qualifications: maybe "Preferred – Medicaid CM" etc? Actually Knowledge And Skills includes many items; we could split: Qualifications = knowledge of medical terminology, preferred Medicaid CM, ability to make sound decisions, etc. Skills = interpersonal, team player, analytical, computer use, etc. But we can also just put all under Skills and leave Qualifications empty? But we must not emit empty headings. So we need to decide what goes where.
Better: Use Requirements for education/experience. Use Qualifications for knowledge and skills that are more technical: knowledge of medical terminology, preferred Medicaid CM, knowledge of contracts, enrollment, billing & claims coding/processing, managed care principles, ability to analyze and resolve problems, ability to use PC and software. Use Skills for interpersonal/behavioral: Team Player, Strong Analytical, Interpersonal Skills, Good Oral and Written Communication skills, ability to make sound decisions under supervision (maybe that's more qualification). But we can adjust.
Let's extract:
Knowledge And Skills bullet list (as paragraph):
- 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.
We can split:
Qualifications: knowledge of medical terminology, preferred Medicaid CM, knowledge of contracts, enrollment, billing & claims coding/processing, managed care principles, ability to analyze and resolve problems with minimal supervision, ability to use PC and software.
Skills: Good Oral and Written Communication skills, ability to make sound decisions under direction of Supervisor, Team Player, Strong Analytical, Interpersonal Skills.
But ability to make sound decisions could be qualification; but okay.
Now Responsibilities: combine all duty paragraphs.
Let's list duties from What You'll Do:
- 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 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.
Letters Team:
- 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.
We can combine into a - list.
Now Benefits: list.
- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement
Pay: Salary Range $44,600 - $59,745 plus description maybe we can keep just the range; but we should preserve all substantive info. The description about compensation range being specific to job level etc. That's substantive; we can include as a
after the heading.
Schedule: not present, omit.
Now format: Use
for each section heading. Use
for prose. Use
- for lists.
We must not include any extra text outside HTML.
Let's craft:
About the Role
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.
- Handles initial screening for pre-certification requests from physicians/members via incoming calls or correspondence based on scripts and workflows, under the oversight of clinical staff.
- Assists members with finding providers, resolving problems and answering questions regarding obtaining services, filing appeals, and preventive health activities.
- Makes outbound calls to engage members in Case Management and to complete necessary health assessments (IHS/HRA, CNA/CMNA, MLTSS Elig Survey).
- Educates members regarding preventive health activities and services.
- Assists members to make appointments with PCP, specialists, and/or transportation.
- Handles 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 addresses gaps in member's preventative care.
- Reviews 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.
But we may have duplicated some items; we need to ensure we didn't miss any. Also we combined some.
We need to ensure we didn't lose any duty: "Non Clinical staff members are not responsible for conducting any UM review activities that require interpretation of clinical information." That's a statement about what they don't do; maybe we can include as a note. Could be included as a list item: "Non-clinical staff are not responsible for UM review activities requiring interpretation of clinical information." We'll add.
Also "Upon collection of clinical and non-clinical information MCC can authorize services based upon scripts or algorithms used for pre-review screening." Already covered.
Now Requirements:
Requirements
- High School Diploma or GED required.
- Preferred 1‑2 years of customer service or medical support related experience.
Qualifications:
Qualifications
- Knowledge of medical terminology; preferred Medicaid CM.
- Knowledge of contracts, enrollment, billing & claims coding/processing.
- Knowledge of managed care principles.
- Ability to analyze and resolve problems with minimal supervision.
- Ability to use a personal computer and applicable software and systems.
Skills:
Skills
- Good oral and written communication skills.
- Ability to make sound decisions under the direction of a supervisor.
- Team player with strong analytical and interpersonal skills.
Benefits:
Benefits
- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement
Pay:
Pay
Salary range: $44,600 – $59,745. This compensation range is specific to the job level and takes into account education, experience, licensure, certifications, geographic location, and internal equity.
We should not include the extra sentences about compensation decisions being dependent on circumstances etc? That's also substantive. Could include as part of same paragraph.
Let's include: "Compensation decisions are dependent on the circumstances of each case." Add to same .
Now ensure no boilerplate: removed EEO, disclaimer about residency, etc.
Check for any repeated content: we have "Acts as liaison with providers, members and Care Managers." Already in responsibilities
after the heading. Schedule: not present, omit. Now format: Use
for each section heading. Use
for prose. Use
- for lists.
We must not include any extra text outside HTML.
Let's craft:
About the Role
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.
- Handles initial screening for pre-certification requests from physicians/members via incoming calls or correspondence based on scripts and workflows, under the oversight of clinical staff.
- Assists members with finding providers, resolving problems and answering questions regarding obtaining services, filing appeals, and preventive health activities.
- Makes outbound calls to engage members in Case Management and to complete necessary health assessments (IHS/HRA, CNA/CMNA, MLTSS Elig Survey).
- Educates members regarding preventive health activities and services.
- Assists members to make appointments with PCP, specialists, and/or transportation.
- Handles 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 addresses gaps in member's preventative care.
- Reviews 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.
Requirements
- High School Diploma or GED required.
- Preferred 1‑2 years of customer service or medical support related experience.
Qualifications
- Knowledge of medical terminology; preferred Medicaid CM.
- Knowledge of contracts, enrollment, billing & claims coding/processing.
- Knowledge of managed care principles.
- Ability to analyze and resolve problems with minimal supervision.
- Ability to use a personal computer and applicable software and systems.
Skills
- Good oral and written communication skills.
- Ability to make sound decisions under the direction of a supervisor.
- Team player with strong analytical and interpersonal skills.
Benefits
- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement
Pay
Salary range: $44,600 – $59,745. This compensation range is specific to the job level and takes into account education, experience, licensure, certifications, geographic location, and internal equity.
We should not include the extra sentences about compensation decisions being dependent on circumstances etc? That's also substantive. Could include as part of same paragraph. Let's include: "Compensation decisions are dependent on the circumstances of each case." Add to same. Now ensure no boilerplate: removed EEO, disclaimer about residency, etc. Check for any repeated content: we have "Acts as liaison with providers, members and Care Managers." Already in responsibilities