Managed Care Specialist

Overview

• The Managed Care Specialist role focuses on resolving managed care claims efficiently and accurately.
• Collaborate with payers to address payment errors and discrepancies.
• Utilize your expertise in Medicare, Medicaid, and managed care billing.
• Work closely with the Revenue Cycle team to ensure claims resolution.
• Create and manage project spreadsheets for payer submissions.
• Track responses and monitor performance of recoveries.
• Prepare detailed reports and appeals to resolve underpayments.
• Contribute to achieving organizational goals through effective communication.
• Enhance operational efficiency by identifying and addressing billing issues.

Key Responsibilities & Duties

• Resolve managed care denied and underpaid claims promptly.
• Understand managed care contracts and payment methodologies.
• Collaborate with payers to address payment errors and discrepancies.
• Prepare and submit appeals letters and monthly reports.
• Track responses and monitor recovery performance.
• Audit claim payments and identify discrepancies affecting accounts receivable.
• Work closely with the Revenue Cycle Director to resolve issues.
• Utilize billing systems to identify and address payment discrepancies.
• Maintain detailed records and ensure compliance with organizational policies.

Job Requirements

• Bachelor's degree in a related field preferred; high school diploma or GED required.
• Minimum 5 years of experience in health insurance and skilled nursing home billing.
• Proficiency in Medicare, Medicaid, and managed care billing and reimbursement.
• Strong skills in Excel, patient accounting systems, and provider portals.
• Ability to work independently, meet deadlines, and troubleshoot effectively.
• Excellent communication skills for internal and external collaboration.
• Detail-oriented with strong critical thinking and organizational abilities.
• Experience with billing systems like Netsmart/MyUnity preferred.
• Knowledge of EOBs, remittance advice, and managed care contracts.