Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

This position supports the Clinical Operations functions and acts as a liaison between members, physicians, delegates, operational business members and member service coordinators. Responsible for providing leadership and guidance to non-clinical team and handle escalated issues/problems.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 verify benefits and courses of treatment.

Collect and collate information required to handle escalated phone/correspondence inquiries.

Upon completion of inquiry investigation/resolution, initiate call back or correspondence to physicians/members to coordinate/verify case completion.

Assist with on-boarding and training of newly hired Managed Care Coordinators I.

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 is not responsible for conducting any UM review activities that require interpretation of clinical information.

Performs initial screening of precertification requests from physicians/members received via incoming calls or correspondence using established scripts and workflows under the oversight of clinical /supervisory 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 in order to engage members in Case Management and to complete the necessary health assessment(s) (IHS/HRA, CNA/CMNA, MLTSS Elig Survey*).

Distributes new case assignments to the Case Management Clinical Staff.

Reviews medical, dental and vision claims and address gaps in member's preventative care.

Educates members regarding preventive health activities and services.

Assists members making appointments with their PCP, specialists, and/or transportation, etc. Process PCP, demographic changes and new ID cards as requested by members.

Triage and distribute referrals from Member Services and incoming faxes from providers.

Addendum  For Behavioral Health Clinical Operations Only:

Required to work one holiday shift per year

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Education/Experience:

High School Diploma/GED required.

Prefer 3-5 years customer service experience

Knowledge:

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

Skills and Abilities:

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

Travel:

May require some travel.

Salary Range:

$48,600 - $65,100

​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity.  This range has been created in good faith based on information known to Horizon at the time of posting.  Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

Comprehensive health benefits (Medical/Dental/Vision)

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.  Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.