Managed Care Coordinator II (Bilingual - Spanish Speaking)
Horizon Blue Cross Blue Shield of New Jersey, Parsippany, NJ, United States
Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey's health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best‑in‑class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.
About the Role
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 the non‑clinical team and handling escalated issues/problems.
What You'll Do
Review 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.
Initiate 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 backs or correspondence to physicians/members to coordinate/verify case completion.
Assist with onboarding and training of newly hired Managed Care Coordinators I.
Act 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.
Perform 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
Assist members with finding providers, resolving problems and answering questions regarding anything from how to obtain services to how to file an appeal.
Distribute new case assignments to the Case Management Clinical Staff.
Review medical, dental and vision claims and address gaps in members’ preventative care.
Educate members regarding preventive health activities and services. Assist members making appointments with their PCP, specialists, and/or transportation. 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 – Behavioral Health Clinical Operations Only
Required to work one holiday shift per year.
Addendum – Letters Team Only
Review medical and administrative documentation for accuracy, grammar, and compliance with regulatory standards.
Perform initial screening of determination letters, ensuring clarity and compliance before distribution.
Make sound, timely decisions under the direction and supervision of a designated Supervisor.
Medically Certified Spanish Translator Only
Review medical and administrative documentation for accuracy, grammar, and compliance with regulatory standards in both English and Spanish.
Translate clinical and non‑clinical documents between English and Spanish, ensuring precise medical terminology and context.
Assist in onboarding and training of new Managed Care Coordinators, providing guidance on language protocols and workflow processes.
What You Bring
Education/Experience:
High School Diploma/GED required.
Prefer 3–5 years customer service experience.
Knowledge:
Knowledge of medical terminology.
Good oral and written communication skills.
Ability to make sound decisions under the direction of a Supervisor.
Prefer knowledge of contracts, enrollment, billing & claims coding/processing.
Prefer knowledge of 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.
Why Horizon?
At Horizon, you'll do meaningful work that directly improves lives while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we'd love to hear from you!
Salary Range
$50,100 - $67,095
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
Disclaimer
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. 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.
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.
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About the Role
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 the non‑clinical team and handling escalated issues/problems.
What You'll Do
Review 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.
Initiate 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 backs or correspondence to physicians/members to coordinate/verify case completion.
Assist with onboarding and training of newly hired Managed Care Coordinators I.
Act 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.
Perform 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
Assist members with finding providers, resolving problems and answering questions regarding anything from how to obtain services to how to file an appeal.
Distribute new case assignments to the Case Management Clinical Staff.
Review medical, dental and vision claims and address gaps in members’ preventative care.
Educate members regarding preventive health activities and services. Assist members making appointments with their PCP, specialists, and/or transportation. 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 – Behavioral Health Clinical Operations Only
Required to work one holiday shift per year.
Addendum – Letters Team Only
Review medical and administrative documentation for accuracy, grammar, and compliance with regulatory standards.
Perform initial screening of determination letters, ensuring clarity and compliance before distribution.
Make sound, timely decisions under the direction and supervision of a designated Supervisor.
Medically Certified Spanish Translator Only
Review medical and administrative documentation for accuracy, grammar, and compliance with regulatory standards in both English and Spanish.
Translate clinical and non‑clinical documents between English and Spanish, ensuring precise medical terminology and context.
Assist in onboarding and training of new Managed Care Coordinators, providing guidance on language protocols and workflow processes.
What You Bring
Education/Experience:
High School Diploma/GED required.
Prefer 3–5 years customer service experience.
Knowledge:
Knowledge of medical terminology.
Good oral and written communication skills.
Ability to make sound decisions under the direction of a Supervisor.
Prefer knowledge of contracts, enrollment, billing & claims coding/processing.
Prefer knowledge of 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.
Why Horizon?
At Horizon, you'll do meaningful work that directly improves lives while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we'd love to hear from you!
Salary Range
$50,100 - $67,095
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
Disclaimer
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. 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.
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.
#J-18808-Ljbffr