Job Description

About the Role

We are seeking a Medicaid and Insurance Case Specialist with strong experience working for or alongside major Managed Care Organizations (MCOs) in New Jersey. The ideal candidate will have a deep understanding of NJ Medicaid programs, waiver services, and insurance case management processes. This position will focus on supporting members and families in navigating eligibility, authorizations, and service coordination while ensuring compliance with state and MCO policies.

Key Responsibilities

Case Management and Support

• Manage a caseload of members requiring assistance with Medicaid, insurance benefits, and waiver services.

• Guide clients through eligibility, enrollment, and authorization processes for NJ Medicaid programs.

• Serve as the primary point of contact for members, families, and providers, ensuring timely resolution of service and coverage issues.

Coordination and Liaison

• Collaborate with discharge planners, social workers, physicians, and other healthcare professionals to coordinate care plans.

• Act as a liaison between clients, caregivers, providers, and MCO case managers to address insurance or service challenges.

• Facilitate communication between home care agencies and MCOs to streamline service authorizations and claims processing.

Compliance and Documentation

• Maintain accurate case records in compliance with Medicaid and MCO standards.

• Monitor program requirements and ensure services are delivered in line with state and federal regulations.

• Stay current with NJ Medicaid policy updates, including Managed Long-Term Services and Supports (MLTSS) and other waiver programs.

Member Advocacy and Education

• Educate members and families on available benefits, waiver programs, and care options.

• Advocate on behalf of clients to resolve service access or coverage disputes.

• Support families during transitions of care to ensure continuity and quality of services.

Qualifications

Experience

• Minimum of 3–5 years of experience in insurance case management, Medicaid programs, or MCO operations.

• Direct experience with New Jersey Medicaid, MLTSS, and waiver programs strongly preferred.

• Prior work with one of the state’s leading MCOs (Amerigroup, Horizon NJ Health, UnitedHealthcare Community Plan, WellCare, or Aetna Better Health) is highly desirable.

Skills & Competencies

• Strong knowledge of NJ Medicaid regulations, waiver programs, and insurance case management practices.

• Ability to manage complex caseloads with attention to detail and regulatory compliance.

• Excellent communication and interpersonal skills for working with diverse populations.

• Strong problem-solving, negotiation, and advocacy skills.

• Proficiency in case management systems and Microsoft Office Suite.

Education

• Bachelor’s degree in Social Work, Nursing, Healthcare Administration, or related field preferred.

• Equivalent experience may be considered.

Benefits

• Competitive salary with annual performance incentives.

• Comprehensive health, dental, and vision insurance.

• Paid time off and retirement plan options.

• Opportunities for professional growth within the organization.

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