Managed Care Coordinator

This position supports Health Services and Utilization Management functions and serves as a liaison between Members, Physicians, Delegates, Operations teams, and Member Service Coordinators.

• Review service requests for completeness, including collection and transfer of non-clinical data and acquisition of structured clinical information from physicians and patients.
• Conduct initial screening for pre-certification requests via calls or correspondence, following established scripts and workflows under clinical supervision.
• Prepare, document, and route cases in the appropriate system for clinical review.
• Initiate callbacks and correspondence with members and providers to coordinate and clarify benefits.
• Follow up on inquiries to ensure case completion and proper communication with physicians and members.
• Review medical policy-related issues or claims in pending status.
• Authorize services based on predefined scripts or algorithms after collecting required clinical and non-clinical information.
• Ensure no clinical interpretation is performed, as this role is strictly non-clinical.
• Perform additional tasks as assigned by management.

Education:

• High School Diploma (required)
• Some college education (preferred)

Work Experience:

• 12 years of experience in customer service or a medical support role (preferred)

Skills & Knowledge:

• Knowledge of medical terminology
• Strong verbal and written communication skills
• Ability to make sound decisions under supervision
• Familiarity with contracts, enrollment, billing, and claims processing (preferred)
• Understanding of managed care principles (preferred)
• Strong analytical and problem-solving abilities with minimal supervision
• Proficiency in using computers and relevant software systems
• Strong interpersonal skills and ability to work effectively in a team environment