CLINICAL ADMINISTRATIVE COORDINATOR JOB DESCRIPTION

A Clinical Administrative Coordinator owns the intake, triage, and referral workflows that keep members moving through Medicare, Medicaid, and Medicare Advantage programs without gaps in coverage or delays in care. This role sits within health plan operations teams, answering to clinical supervisors while serving as the primary administrative contact for both members and provider networks. ICD-10 and CPT coding accuracy, DOL-compliant benefit determination letters, and HIPAA-regulated information handling all fall within its scope.

As the Clinical Administrative Coordinator, you will manage member intake, process prior authorizations, conduct telephonic outreach, and ensure benefit determinations reach providers and enrollees within regulatory timeframes, directly supporting continuity of care across the plan's network. The position operates within a managed care operations unit, supporting clinical staff, community partner programs, and the provider network across inpatient, outpatient, and post-discharge settings.

Career Impact: Hands-on experience processing Medicare Advantage and Medicaid authorizations builds a specialized credential set that is transferable across health plans, ACOs, and managed care organizations.

Business Impact: Gaps in member outreach and delayed prior authorization decisions lead to avoidable admissions and coverage lapses — this role prevents those outcomes for the members and providers depending on the plan.

Growth Opportunity: Proficiency in care coordination workflows and regulatory compliance positions coordinators for advancement into care management, utilization review, or clinical operations supervisor roles.

• Manage incoming and outgoing referral requests, prior authorizations, and benefit determination notifications within DOL-mandated timeframes.
• Conduct telephonic outreach to members, including DSNP enrollees, to address gaps in care and connect them with appropriate provider appointments.
• Triage and document care coordination notification cases, forwarding complex needs to clinical staff for risk validation.
• Process out-of-network requests for in-network benefit consideration across applicable plan products and employer group contracts.
• Verify ICD-10 and CPT coding accuracy on submitted claims and authorization requests before clinical routing.
• Coordinate post-discharge transitions, including scheduling follow-up appointments and arranging transportation for members leaving inpatient facilities.
• Support members with social determinants of health by linking them to community resources and partner programs.
• Maintain member records in compliance with HIPAA and applicable state and federal regulations throughout all interactions.

• High school diploma or GED, or equivalent work experience.
• 2 or more years of customer service or administrative experience in a healthcare, insurance, or managed care environment, with demonstrated ability to handle high call volume.
• Working knowledge of medical terminology, ICD-10 and CPT coding conventions, and Medicare or Medicaid program structures.
• Experience managing referral intake, prior authorizations, or benefit determination workflows in a clinical or health plan setting.
• Ability to maintain confidential health information in accordance with HIPAA and related federal and state regulations.
• Demonstrated competency in multi-system data entry, telephonic member contact, and simultaneous task management in a production environment.
• Strong written and verbal communication skills sufficient to convey benefit determinations accurately to providers and members.

• Bachelor's degree in social work, public health, or a related field, or a Medical Assistant certification.
• Experience with DSNP populations, Medicare Advantage plan administration, or community outreach and advocacy programs.
• Bilingual proficiency in English and Spanish or another language spoken by the plan's member population.
• Prior telecommuting or remote healthcare operations experience with a documented track record of meeting productivity metrics independently.

• Prior authorization turnaround time, measured against DOL-mandated regulatory windows.
• Gap-in-care closure rate across the assigned member caseload per reporting period.
• Outreach contact rate, reflecting the percentage of assigned members successfully reached per program guidelines.
• ICD-10 and CPT coding accuracy rate on processed authorization requests.
• Schedule adherence percentage, tracked against established production standards.
• Typical tools: care management platforms (commonly used in health plan operations); productivity suites (commonly Microsoft Word, Excel, Outlook).

• Base Salary Range: $38,000 to $52,000 per year, depending on seniority and location.
• Bonus: Annual performance bonus of 3 to 5 percent of base salary.
• Equity: Not typically offered at this level.
• Health Benefits: Medical, dental, and vision coverage; employer contribution standard.
• PTO: 15 to 20 days per year plus standard federal holidays.
• Common Perks: Remote or hybrid eligibility, employee assistance program, tuition reimbursement for healthcare-related coursework.

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Employment is contingent on successful completion of a background check and, where applicable, drug screening consistent with healthcare industry standards. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other characteristic protected under federal, state, or local law. Reasonable accommodations are available to applicants and employees with disabilities upon request. Candidates must be authorized to work in the United States.

The Senior Clinical Administrative Coordinator owns benefit coverage determination, prior authorization triage, and DOL-compliant member communications across a health plan's provider and enrollee network, ensuring care coordination cases reach the right clinical staff for risk validation. Reporting to a clinical or operations supervisor, the coordinator works alongside care coordinators and provider offices to process out-of-network requests, verify ICD-10 and CPT coding, and resolve customer service inquiries that span outpatient, home health, and DME services.

Key Responsibilities

• Respond to incoming provider and enrollee calls.
• Resolve customer service inquiries.
• Provide excellent customer service to both providers and enrollees.
• Constantly meet established productivity, schedule adherence, and quality standards while maintaining good attendance.
• Receive care coordination notification cases for non-clinical assessment and intervention and provide appropriate triage.
• Process out-of-network requests for consideration of in-network level of benefits for physician specialty referrals for appropriate products.
• Process notification requirements for outpatient procedures, home health, DME, transition of care, and network gap issues.
• Determine benefit coverage issues based on employer group contracts.
• Set up, document, and triage cases for clinical coverage review.
• Ensure all potential member needs are identified and forwarded to the appropriate care coordinator for risk validation when applicable.
• Process letters within DOL time frames.
• Verify appropriate ICD-10 and CPT coding usage.
• Communicate to providers and members benefit determinations within DOL time frames.
• Assist with faxes and emails.

Education & Experience

• Bachelor's degree or higher required.
• 1+ years of professional experience in a medical office or customer service environment.
• Experience working within the healthcare industry, hospital, physician's office, or medical clinical setting.
• Experience with medical terminology, ICD-9 and CPT codes, and Medicare or Medicaid services.
• Professional experience in a clerical or administrative support related role.
• Call center experience preferred.
• Proficiency in Microsoft Word, including creating, editing, saving, and sending documents.
• Computer proficiency including the ability to learn new computer system applications.
• Ability to multi-task and work in a fast-paced, dynamic, rapidly changing environment.
• Excellent oral and written communication skills.
• Strong aptitude for working in a production-driven environment and ability to work autonomously.
• Must reside within an MST location with access to an approved high-speed internet connection.

Embedded within a managed care operations team, the Clinical Administrative Coordinator manages DSNP member telephonic outreach, referral intake, and gap-in-care closure while serving as a subject matter expert resource for colleagues handling benefit, eligibility, and service coordination questions. Working closely with hospitals, clinics, and the clinical team, this coordinator maintains HIPAA-compliant health records, tracks admission and discharge information, and resolves provider and member inquiries in environments that require evening hour availability.

Core Functions

• Complete telephonic outreach to DSNP members utilizing auto dialer and manual dialing.
• Educate members on gaps in care and assist with scheduling provider appointments.
• Assist members with social determinants of health and link to community resources.
• Ensure members have access to PCP.
• Identify gaps in care and assist in closure of gaps.
• Conduct outreach to members on caseload consistent with program guidelines.
• Consistently meet metrics, both quality and performance.
• Provide excellent customer service to both members and providers.
• Maintain schedule adherence and good attendance.
• Maintain confidential health information according to state and federal regulations including HIPAA.
• Act as a subject matter expert and go-to resource for other team members.
• Manage the intake of members or the admission and discharge information post notification.
• Work with hospitals, clinics, facilities, and the clinical team to manage requests for services.
• Manage the referral process, including intake, notification, and census roles.
• Resolve inquiries from members and providers.

Required Qualifications

• High school diploma or GED or higher required.
• Bachelor's degree or higher in social work, public health, or related field preferred.
• 2+ years of call center or telephonic customer service experience.
• 1+ years of professional experience in an office setting using the telephone and computer as primary instruments.
• 1+ years of healthcare or insurance experience, or social work, community outreach, or advocacy experience.
• 1+ years of experience analyzing and solving customer problems.
• Medicaid or Medicare experience preferred.
• Experience working with medical terminology.
• Work experience using Microsoft Word, Microsoft Excel, and Microsoft Outlook.
• Must be comfortable maintaining metrics and goals, working on the phone and multiple systems simultaneously, and making outreach to members without prior engagement.
• Excellent organizational skills and telephone etiquette.
• Bilingual in English and Spanish or another language preferred.

Reporting to the clinical operations or service coordination leadership, the Clinical Administrative Coordinator manages member triage, referral processing, and post-discharge transitions for enrolled members and community partner beneficiaries across inpatient, outpatient, and provider network settings. Partnering with PCP networks, physician offices, and hospital facilities, this coordinator arranges follow-up appointments, transportation, and community outreach documentation to ensure members receive continuous, coordinated healthcare services.

Primary Duties

• Manage the referrals process, process incoming and outgoing referrals, and prior authorizations.
• Conduct outreach calls to members and beneficiaries post facility discharge.
• Support enrolled members and beneficiaries of community partners.
• Collaborate with PCP network, physician offices, and hospital facilities within the service area.
• Support members with coordinating healthcare services.
• Arrange post-discharge appointments, transportation, and transition of members across the continuum of care.
• Make appropriate referrals to the customer care team to support benefit, billing, payment, and eligibility needs.
• Assist with referrals and calls received by the center for service coordination department and complete community outreach and documentation.

Qualifications & Experience

• High school diploma or GED required.
• Some college or undergraduate education preferred.
• Medical Assistant certification preferred.
• 1+ years of customer service experience analyzing and solving customer problems.
• Experience working within the healthcare industry.
• Experience working with Centers for Medicare and Medicaid Services, especially Medicare and Medicare Advantage programs.
• Working knowledge of medical terminology to communicate with members, beneficiaries, and providers.
• Knowledge of community resources.