Member Care Coordinator / Utilization Management Support

Job Summary

This position supports the Health Services and Utilization Management functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members, and Member Service Coordinators.

Location : Middle to South New Jersey
Candidates must be willing to travel to Hopewell, NJ at least once per month.

Key Responsibilities

• Review service requests for completeness of information, including collection and transfer of non-clinical data and acquisition of structured clinical data from physicians and patients.
• Handle initial screening for pre-certification requests from physicians and members via incoming calls or correspondence, following established scripts and workflows under the oversight of clinical staff.
• Prepare, document, and route cases in the appropriate system for clinical review.
• Initiate callbacks and correspondence to members and providers to coordinate and clarify benefits.
• Follow up with physicians and members regarding case completion and inquiry resolution.
• Review professional medical and claim policy-related issues or claims in pending status.
• Authorize services based on scripts or algorithms used for pre-review screening after collecting required clinical and non-clinical information.
• Perform additional duties and relevant tasks as assigned by management.

Note: Non-clinical staff members are not responsible for conducting Utilization Management review activities that require interpretation of clinical information.

Required Qualifications

Education

• High School Diploma required
• Some college coursework preferred

Experience

• Healthcare industry experience required
• Call center experience required
• 1–2 years of customer service or medical support experience preferred

Skills & Knowledge

• Knowledge of medical terminology required
• Strong oral and written communication skills required
• Ability to make sound decisions under supervisor guidance required
• Proficiency in Microsoft Word and Excel required
• Knowledge of contracts, enrollment, billing, and claims coding/processing preferred
• Knowledge of managed care principles preferred
• Strong analytical, interpersonal, and problem-solving skills
• Ability to work independently with minimal supervision preferred
• Team-player attitude with strong customer service orientation

Additional Requirements

• Candidates must reside in Middle to South New Jersey
• Must be able to travel to Hopewell, NJ at least once per month
• Microsoft Word and Excel assessment quiz scores must be included on the resume