Member Care Coordinator

About the role

A Member Care Coordinator sits at the intersection of Member Experience and Clinical Operations. The role of a Member Care Coordinator is to ensure that members receive timely, coordinated, and high quality care; acting as the “glue” between the Clinical, Coaching, and Operational teams. They ensure smooth handoffs between teams, including but not limited to, tracking lab results, medication approvals, and any necessary clinical follow up to ensure members proceed through their journey seamlessly.

Key responsibilities

• Execute critical clinical administrative workflows focusing on resolving readiness barriers to accelerate members toward provider review and medication access.
• Facilitate provider workflow efficiency by preparing clinical documents and proactively triaging member needs for specialty support.
• Facilitate structured handoffs of critical information to Clinical and Coaching teams to ensure timely follow-up regarding changes in medication, denials, or approved exception paths.
• Engage in cross-functional meetings and work collaboratively with others departments to improve and maintain a high level of member care.
• Identify and formally report recurring systemic issues, submission errors, or trends that contribute to operational friction.
• Manage the end-to-end medication access workflow with complete ownership, including the proactive gathering of relevant clinical data, coordinating with clinicians for additional necessary information, complex Prior Authorization (PA) submission, denial investigation, appeal documentation, final determination and overrides when applicable.
• Proactively contact members via phone and secure message to request necessary information (e.g., previous prescription history, documentation) and deliver clarity regarding complex PA status changes or delays.
• Conduct outbound calls to insurance carriers, PBMs, and pharmacies to obtain specific case statuses, track documentation, and secure approvals.
• Ensure all communication, investigation notes, and PA statuses are accurately logged in the case management system (e.g., Zendesk, MJD) to maintain a complete and auditable member record.
• Initiate and resolve pharmacy-level rejections (e.g., refill too soon, insurance coding errors, wrong dose dispensed) by conducting outbound calls to dispensing pharmacies and PBM help desks.
• Troubleshoot technical or administrative insurance issues that prevent successful claims processing.

Qualifications

• Completion of a formal medical assisting program is highly valued. Preference will be given to candidates who hold a national certification, such as Certified Medical Assistant (CMA) awarded by the AAMA or Registered Medical Assistant (RMA) awarded by the AMT.
• Familiarity with case management systems (e.g., Zendesk), Electronic Health Records (EHR), and PA/e-prescribing platforms is highly desirable.
• 2+ years of high-volume customer service, call center, or patient advocacy experience, preferably in a healthcare, pharmacy, or PBM setting.
• Demonstrated track record of managing complex, multi-step processes where follow-up and persistence are critical to success (i.e., comfortable making multiple calls to solve a single problem).
• Exceptional verbal and written communication skills with the proven ability to handle challenging, escalated calls/messages with professionalism and empathy.

Benefits

• Enjoy a generous paid time off policy, including multiple paid company holidays, wellness days, and floating holidays to support your work-life blend.
• Medical, dental, and vision benefit options to keep you and your family healthy.
• Calibrate-funded disability and basic life insurance, ensuring peace of mind during unforeseen events.
• Access to several wellness programs, including a complimentary Headspace membership, and therapy on your schedule with Headspace Care.
• Employee Assistance Program through Principal to receive counseling on a wide range of topics.
• Remote-first ways of working, with the flexibility to work from any state.
• Competitive paid parental leave program to support new parents.

Our values

• Members First. Always.
• Outcomes That Matter.
• Integrated Care Wins.
• Relentless Improvement.
• Great Partners.