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.

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.

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:

High School Diploma required. Some College preferred

Prefer 1-2 years of 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, enrolment, billing & claims coding/processing

Prefer knowledge Managed Care principles

Prefer the ability to analyse 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