Managed Care Coordinator II, Bilingual – Spanish

Job not on LinkedIn

🔥 18 hours ago

🦌 Connecticut, New Jersey, +2 more states – Remote

🦌 Connecticut – Remote 🏖️ New Jersey – Remote 🗽 New York – Remote 🔔 Pennsylvania – Remote

💵 $50.1k - $67.1k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

💬 Bilingual

👻 Ghost score 18%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Horizon Connect @ Wall BCBSNJ

WebsiteLinkedInAll Job Openings

2 - 10 employees

⚕️ Healthcare Insurance

🏥 Healthcare

Healthcare Insurance • Healthcare

Horizon Connect @ Wall BCBSNJ is a LinkedIn presence or local program/office associated with Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ). Based on the name and context, it appears to be connected to Horizon BCBSNJ’s health insurance operations and local outreach or member/provider engagement in the Wall, NJ area. Publicly available information provided is limited and mostly LinkedIn site chrome rather than a company profile, so this description is conservative and based on the affiliation indicated by the name.

📋 Description

• Support Clinical Operations and act as a liaison between members, physicians, delegates, operational business members and member service coordinators. • Provide leadership and guidance to the non-clinical team and handle escalated issues/problems. • Review service requests for completeness, collect and transfer non-clinical data, and acquire structured clinical data from physicians/patients. • Prepare, document and route cases for clinical review. • Initiate callbacks and correspondence to members and providers to coordinate and verify benefits and courses of treatment. • Collect and collate information required to handle escalated phone and correspondence inquiries. • Investigate and resolve inquiries, then coordinate and verify case completion with physicians/members. • Assist with onboarding and training newly hired Managed Care Coordinators I and other Managed Care Coordinators. • Act as liaison with providers, members and Care Managers. • Authorize services based on scripts or algorithms for pre-review screening under clinical/supervisory oversight. • Perform initial screening of precertification requests using established scripts and workflows. • Assist members with finding providers, resolving problems, answering questions, filing appeals and obtaining services. • Engage members in Case Management and complete health assessments. • Distribute new case assignments to Case Management Clinical Staff. • Review medical, dental and vision claims and address gaps in preventive care. • Educate members about preventive health activities and services. • Assist members with appointments, transportation, PCP and demographic changes, and new ID cards. • Triage and distribute referrals and provider faxes. • Review medical and administrative documentation for accuracy, grammar and regulatory compliance. • Screen determination letters before distribution. • Translate clinical and non-clinical documents between English and Spanish using precise medical terminology. • Make timely decisions under supervisor direction.

🎯 Requirements

• High School Diploma/GED required. • 3-5 years customer service experience. • Medical certification translator education (Letter’s Team, Medically Certified Spanish Translator only). • Requires knowledge of medical terminology. • Requires good oral and written communication skills. • Requires ability to make sound decisions under the direction of Supervisor. • Requires knowledge of clinical standards of care and Star measures. • Requires operational knowledge of health care delivery systems and health insurance industry. • Requires appreciation for strategic planning. • Requires knowledge of NCQA accreditation standards and state and federal laws applicable to health plan appeals and grievances (Letters Team, Medically Certified Spanish Translator). • Requires knowledge of CMS and state regulatory requirements (Letters Team, Medically Certified Spanish Translator only). • Team Player, Strong Analytical, Interpersonal Skills. • Required to work one holiday shift per year. • May require some travel. • Review and translate documents in both English and Spanish. • Prefer knowledge of contracts, enrollment, billing & claims coding/processing. • Prefer knowledge of Managed Care principles. • Prefer ability to analyze and resolve problems with minimal supervision. • Prefer ability to use a personal computer and applicable software and systems.

🏖️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision) • Retirement Plans • Generous PTO • Incentive Plans • Wellness Programs • Paid Volunteer Time Off • Tuition Reimbursement