Medical Services Coordination Specialist I

Job Description: This position supports the workflow of the Medical Services division. The Medical Services Coordination Specialist provides support for any of the programs of Behavioral Health, Quality Management, or Member Care Management. This position is responsible for adhering to regulatory requirements and helping to support and connect members to appropriate internal Health Plan resources, Clinical Case Management team, and external community support systems.

Summary

This position supports the workflow of the Medical Services division. The Medical Services Coordination Specialist provides support for any of the programs of Behavioral Health, Quality Management, or Member Care Management. The role adheres to regulatory requirements while helping members connect to internal Health Plan resources, Clinical Case Management, and external community support systems.

Essential Accountabilities

Level I

• Review and prep clinical case for clinical staff.
• Assess member’s needs using Health Plan approved case management guidelines and assessment tools; make appropriate referrals to clinical programs.
• Collaborate with the clinical care team and enrollees or caregivers to identify and achieve shared treatment goals.
• Manage a caseload productively and keep documentation according to health plan standards.
• Advocate for members, addressing social determinants of health, providing coaching, and placing referrals to case and disease management.
• Link enrollees with resources and empower them to use them effectively, ensuring timely appointments.
• Monitor member engagement and follow up on outstanding actions to close care gaps and complete required assessments.
• Engage members via phone, messaging, and digital tools to support improved health outcomes.
• Identify members with gaps in care, aligning with HEDIS quality measures and Value Based Payment Programs.
• Communicate outreach and education on health care quality metrics, assess barriers, and intervene to assure access or facilitate referrals.
• Coordinate enrollee access to transportation, pharmacy, grocery store, food pantry, and other community resources to meet care plan goals.
• Prepare and assist in handling member and provider correspondence related to disease conditions and program services, ensuring accuracy and timeliness.
• Manage BH/MCM/Quality voice and email inboxes and SIR queues for messages, referrals, and documentation.
• Adhere to unit Service Level Agreements, internal and external regulatory commitments, and timeframes.
• Ensure end-to-end process for care management referrals is accurate and complete by collaborating with other departments.
• Perform non‑care‑manager support duties such as requesting medical records, mailing materials, and answering calls or emails, when non‑clinical.
• Conduct intake assessment and triage functions for calls to appropriate MCM/Quality service area, providing preliminary support to various providers.
• Communicate with members and service providers in accordance with regulatory and organizational guidelines.
• Demonstrate high standards of integrity, supporting the company’s mission, values, Code of Conduct, and Lifetime Way.
• Maintain member privacy in accordance with corporate policies.
• Maintain regular and reliable attendance.
• Perform additional functions as assigned by management.

Level II (in addition to Level I Accountabilities)

• Prioritize work and provide instruction, advice, and guidance to junior staff regarding unit processes and systems.
• Support training and onboarding of new staff.
• Mentor newer staff and troubleshoot unit‑related questions.
• Act as intermediary between staff and management to alert leadership of potential barriers.
• Review procedures and recommend updates to keep workflow relevant.
• Produce care management statistics for department metrics (case and review timeliness, workflow volumes, referrals).

Level III (in addition to Level II Accountabilities)

• Assist supervisor with inventory control and monitoring of department performance standards.
• Monitor workflow, produce reporting and recommendations to management.
• Assist in updating departmental policies and processes; develop performance improvement strategies.
• Handle complex issues, escalated customer questions, and high‑cost member investigations.
• Assess staff training needs and report to supervisor.
• Identify eligibility and coverage issues and assist other staff with related inquiries.
• Collaborate with internal departments on process changes and recommend solutions.

Minimum Qualifications

All Levels

• Minimum of one year experience working in an insurance company, medical assistant, Health Plan customer service, community‑based care coordination, or patient‑facing medical setting.
• Working knowledge of medical terminology.
• Proficiency with Microsoft Office Suite.
• Excellent oral and written communication skills.
• Organizational and interpersonal skills; able to manage multiple tasks under pressure.
• Ability to use department‑specific applications and software (care management system and libraries).
• Ability to apply engagement strategies such as motivational interviewing.
• Attention to detail.

Level II (in addition to Level I Qualifications)

• Minimum of three years experience in insurance or community‑based care coordination or medical setting.
• Develop and apply in‑depth knowledge of complex rules, systems, policies, and regulatory requirements.
• Broad understanding of multiple company areas and collaborative problem‑solving.
• Recognize sensitive issues and know when to elevate concerns to management.
• Demonstrate ability to lead committee activities and support newer team members.
• Consistently exceed productivity standards set by department.
• Find and pursue process improvement opportunities.

Level III (in addition to Level II Qualifications)

• Minimum of five years experience in insurance or medical care setting.
• Thorough knowledge of health plan contracts, regulatory requirements, and unit procedures.
• Knowledge of multiple systems and processes for identifying and resolving data or process issues.
• Precept new staff and manage complex challenges independently.
• Identify process efficiencies and develop action plans.
• Demonstrate presentation skills.

Physical Requirements

• Work prolonged periods sitting and/or standing at a workstation and using a computer.
• Perform tasks while sitting or standing for three or more hours at a time, using keyboard, mouse, or phone.
• Work from a home office for continuous periods to maintain business continuity.
• Travel across the Health Plan service region for meetings and trainings as needed.
• Hear, understand, and speak clearly while using a phone, with or without a headset.

Compensation Range(s)

Level I: $20.40 – $27.00
Level II: $20.80 – $30.80
Level III: $21.20 – $33.03

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on available budget, prior experience, knowledge, skill, and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components may include group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Remote work may be possible for all jobs posted by the Univera Healthcare Talent Acquisition team; this decision is made on a case‑by‑case basis.

Equal Opportunity Employer

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.