This position supports the Clinical Operations functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators
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
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.
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*.)
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.
High School Diploma required. Some College preferred.
Prefer 1-2 years customer service or medical support related position.
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
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
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.