{"id":3741802,"url":"https://alion.io/job/horizon-blue-managed-care-coordinator-ii","title":"MANAGED CARE COORDINATOR II","company":{"id":1809289,"name":"Horizon Blue","domain":"horizonblue.com","url":"https://alion.io/company/horizonblue","size_band":null,"is_staffing_agency":false,"employer_type":"direct","is_intermediary":false,"listed_via":null,"ats_vendor":null,"truth_index":null},"role":"Administrative","role_family":"Administrative","seniority":"middle","employment_type":"full_time","work_mode":"remote","remote_scope":"stated_countries","remote_scope_basis":"posting_text","remote_working_hours":null,"hiring_geo_confidence":"inferred","locations":["New York, United States"],"countries":["US"],"hiring_countries":["US"],"hiring_countries_total":1,"salary":{"min":50100,"max":67095,"currency":"USD","period":"year","gross":null,"usd_annual":67095},"salary_estimate":null,"experience_years_min":3,"visa_sponsorship":false,"relocation_package":false,"has_equity":false,"technologies":[],"status":"live","first_seen_at":"2026-11-04T09:31:11Z","employer_posted_date":null,"last_verified_at":"2026-11-04T09:31:11Z","board_verified":false,"closed_at":null,"days_open":1,"trust":{"level":"not_scored","repost_count":null,"flags":[],"days_open":1},"description":"This a Full Remote job, the offer is available from: United States, New Jersey (USA)\nHorizon 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.\n\nAbout the Role\n\nThis 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.\nWhat You'll Do\n\nResponsibilities:\nPerforms review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients.\n\nPrepare, document and route cases in appropriate system for clinical review.\n\nInitiates call backs and correspondence to members and providers to coordinate and verify benefits and courses of treatment.\n\nCollect and collate information required to handle escalated phone/correspondence inquiries.\n\nUpon completion of inquiry investigation/resolution, initiate call back or correspondence to physicians/members to coordinate/verify case completion.\n\nAssist with on-boarding and training of newly hired Managed Care Coordinators I.\n\nActs as liaison with providers, members and Care Managers.\n\nPerform other relevant tasks as assigned by management.\n\nUtilization Management:\nUpon collection of clinical and non-clinical information, MCC can authorize services based upon scripts or algorithms used for pre-review screening.\n\nNon Clinical staff is not responsible for conducting any UM review activities that require interpretation of clinical information.\n\nPerforms 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.\n\nCase Management:\nAssists members with finding providers, resolving problems and answering questions regarding anything from how to obtain services to how to file an appeal.\n\nMakes 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*).\n\nDistributes new case assignments to the Case Management Clinical Staff.\n\nReviews medical, dental and vision claims and address gaps in member's preventative care.\n\nEducates members regarding preventive health activities and services.\n\nAssists members making appointments with their PCP, specialists, and/or transportation, etc. Process PCP, demographic changes and new ID cards as requested by members.\n\nTriage and distribute referrals from Member Services and incoming faxes from providers.\n\nAddendum For Behavioral Health Clinical Operations Only:\nRequired to work one holiday shift per year\n\nAddendum for Letter’s Team Only:\nReview medical and administrative documentation for accuracy, grammar, and compliance with regulatory standards.\n\nPerform initial screening of determination letters, ensuring clarity and compliance before distribution.\n\nMake sound, timely decisions under the direction and supervision of a designated Supervisor.\n\nMedically Certified Spanish Translator Only:\n\n* Review medical and administrative documentation for accuracy, grammar, and compliance with regulatory standards in both English and Spanish.\n* Translate clinical and non-clinical documents between English and Spanish, ensuring precise medical terminology and context.\n* Assist in the onboarding and training of new Managed Care Coordinators, providing guidance on language protocols and workflow processes.\nDisclaimer:\nThis 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.\n\nWhat You Bring\n\nEducation/Experience:\nHigh School Diploma/GED required.\n\n3-5 years customer service experience.\n\nAdditional licensing, certifications, registrations:\nMedical certification translator education (Letter’s Team, Medically Certified Spanish Translator only).\n\nKnowledge:\nRequires knowledge of medical terminology\n\nRequires Good Oral and Written Communication skills\n\nRequires ability to make sound decisions under the direction of Supervisor\n\nPrefer knowledge of contracts, enrollment, billing & claims coding/processing\n\nPrefer knowledge Managed Care principles\n\nRequires knowledge of clinical standards of care, and Star measures.\n\nRequires operational knowledge of health care delivery systems and health insurance industry.\n\nRequires appreciation for strategic planning.\n\nRequires knowledge of NCQA accreditation standards as well as state and federal laws applicable to health plan appeals and grievances. (Letters Team, Medically Certified Spanish Translator)\n\nRequires knowledge of CMS and state regulatory requirements. (Letters Team, Medically Certified Spanish Translator only)\n\nSkills and Abilities:\nPrefer the ability to analyze and resolve problems with minimal supervision\n\nPrefer the ability to use a personal computer and applicable software and systems\n\nTeam Player, Strong Analytical, Interpersonal Skills\n\nTravel:\nMay require some travel.\n\nWhy Horizon?\n\nAt 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!\nSalary Range:\n$50,100 - $67,095This 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:\nComprehensive health benefits (Medical/Dental/Vision)\n\nRetirement Plans\n\nGenerous PTO\n\nIncentive Plans\n\nWellness Programs\n\nPaid Volunteer Time Off\n\nTuition Reimbursement\n\nDisclaimer:\nHorizon 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.\nHorizon 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. 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