Medical Care Coordinator RN (US Healthcare) Medicare Advantage

Job Title

Medical Care Coordinator RN (US Healthcare) – Medicare Advantage

Location

India / Philippines (Onsite and/or Remote)

Reporting To

Medical Care Coordination Lead / Operations Manager

Role Overview

The Medical Care Coordinator RN is responsible for the accurate intake, documentation, processing, and coordination of medical authorization requests received from providers, members, and internal stakeholders. The role supports utilization management and care coordination activities by ensuring requests are processed accurately, routed appropriately, and completed within established service level agreements (SLAs).

In addition to authorization management, this role supports broader clinical operations as business needs evolve. Responsibilities may include maintaining accurate member records, coordinating with clinical and customer service teams, supporting compliance initiatives, and assisting with cross-functional operational activities.

This position requires strong healthcare operations knowledge, attention to detail, effective communication skills, and strict adherence to regulatory and organizational policies. The role is non-clinical but directly supports clinical decision-making by ensuring complete, accurate, and timely information is available for review.

This is a high-quality, service-critical role supporting Utilization Management and Care Coordination programs for US Healthcare.

Key Responsibilities

Authorization Intake & Processing

• Receive and accurately enter authorization requests received via electronic portals, telephone, fax, and other approved communication channels.
• Review requests for completeness and ensure accurate documentation within designated systems.
• Identify missing or incomplete information and proactively obtain the required documentation from providers or other authorized parties.
• Maintain complete and accurate electronic and hard-copy records in accordance with organizational policies.

Authorization Coordination & Case Management

• Utilize healthcare operations knowledge to analyze contractual, administrative, and authorization-related issues associated with incoming requests.
• Determine when requests require referral to appropriate clinical personnel based on established business and clinical guidelines.
• Coordinate authorization activities with customer service, utilization management, and clinical operations teams.
• Ensure timely routing and follow-up of cases to meet turnaround time requirements.

Customer & Provider Communication

• Communicate professionally with members, providers, vendors, internal departments, and other stakeholders regarding authorization requests and documentation requirements.
• Provide accurate updates regarding authorization status while maintaining confidentiality and compliance with HIPAA requirements.
• Build positive working relationships through courteous, timely, and professional communication.

Documentation, Compliance & Quality

• Maintain complete, accurate, and audit-ready documentation across all systems.
• Ensure all work complies with corporate policies, contractual obligations, quality standards, accreditation requirements, and applicable federal and state regulations.
• Adhere to HIPAA, CMS, and all applicable healthcare compliance requirements.
• Meet established quality, accuracy, productivity, and turnaround time metrics.

Operational Excellence

• Consistently achieve departmental productivity, quality, and SLA performance goals.
• Demonstrate flexibility by supporting multiple operational functions through cross-training.
• Escalate operational issues, system concerns, or complex authorization requests to the supervisor as appropriate.
• Participate in departmental projects, process improvement initiatives, and additional assignments as required.
• Support other clinical operations teams and business functions based on organizational needs.
• Perform other duties as assigned.

Required Experience & Qualifications

Mandatory

• 2–5+ years of experience in US Healthcare Operations.
• Experience in Prior Authorization, Utilization Management, Care Coordination, Medical Claims, or Healthcare Customer Service.
• Working knowledge of medical terminology and healthcare authorization workflows.
• Experience working with healthcare documentation systems or payer platforms.
• Strong analytical, organizational, and problem-solving skills.
• Excellent verbal and written English communication skills.
• Ability to manage multiple priorities while meeting quality and productivity expectations.

Preferred

• Associate's or bachelor's degree in healthcare administration, Life Sciences, Nursing, or a related discipline.
• Experience supporting Medicare, Medicaid, Commercial Health Plans, or Managed Care organizations.
• Knowledge of CMS guidelines, HIPAA, and healthcare compliance requirements.
• Experience in US Healthcare BPO environments.
• Exposure to utilization management or care management platforms.

Key Competencies

• Authorization and healthcare operations knowledge
• Medical terminology proficiency
• Attention to detail and documentation accuracy
• Customer service orientation
• Strong communication and interpersonal skills
• Problem-solving and analytical thinking
• Time management and SLA adherence
• Compliance and quality focus
• Adaptability and cross-functional collaboration

Work Expectations

• Comfortable working in a fast-paced, metrics-driven healthcare operations environment.
• Ability to manage multiple authorization requests while maintaining accuracy and productivity.
• Flexibility to support multiple healthcare programs based on business requirements.
• Mandatory completion of HIPAA, compliance, and program-specific training.
• Willingness to cross-train across utilization management, care coordination, and other operational functions.

Career Path

• Senior Medical Care Coordinator
• Medical Care Coordinator SME / Quality Reviewer
• Medical Care Coordination Lead
• Operations Supervisor