Managed Care Specialist

Overview

• The Managed Care Specialist will handle third-party billing and collections, focusing on Medicare, Medicaid, and Managed Care claims.
• Ensure timely resolution of denied and underpaid claims through effective appeals and communication strategies.
• Collaborate with payers to address payment discrepancies and enhance revenue cycle performance.
• Utilize advanced knowledge of billing systems to audit payments and identify issues affecting accounts receivable.
• Prepare detailed monthly reports and appeals to support financial recovery efforts.
• Work closely with the Revenue Cycle Director to address operational challenges and optimize processes.
• Contribute to the organization’s financial health by ensuring compliance with managed care contracts.
• Participate in team meetings and provide insights for continuous improvement initiatives.

Key Responsibilities & Duties

• Analyze managed care contracts and develop project spreadsheets for payer submissions.
• Draft and submit reconsideration appeals to Managed Care Organizations (MCOs).
• Collaborate with MCO payers to resolve payment errors and underpayments.
• Prepare and submit monthly Excel reports and appeals letters for external recovery efforts.
• Track responses from MCOs and ensure timely follow-up actions.
• Utilize billing systems to monitor recoveries, audit payments, and identify discrepancies.
• Collaborate with the Revenue Cycle Director to address and resolve operational issues.
• Maintain detailed records of appeals and recovery activities for reporting purposes.

Job Requirements

• Minimum of 5 years’ experience in health insurance and skilled nursing home billing.
• Proficiency in Medicare, Medicaid, and Managed Care billing and reimbursement processes.
• Strong knowledge of managed care contracts and payment methodologies.
• Experience with billing systems such as Netsmart/MyUnity and provider portals.
• Ability to analyze Explanation of Benefits (EOBs) and remittance advice.
• Advanced skills in Excel and patient accounting systems.
• Strong communication and problem-solving skills for effective dispute resolution.
• Bachelor's degree in a related field preferred; High School Diploma/GED required.