Managed Care Specialist

Overview

• The Managed Care Specialist plays a crucial role in managing third-party billing and collections for Medicare, Medicaid, and Managed Care claims.
• Ensure timely resolution of denied and underpaid claims through appeals and collaboration with payers.
• Work closely with internal teams and external payers to address payment discrepancies and optimize revenue cycle performance.
• Utilize advanced knowledge of billing systems to monitor and audit claim payments effectively.
• Prepare detailed reports and appeals to resolve payment issues and track recoveries.
• Collaborate with directors to address emerging issues and improve processes.
• Maintain compliance with managed care contracts and reimbursement methodologies.
• Provide detailed analysis and troubleshooting to ensure organizational goals are met.

Key Responsibilities & Duties

• Analyze managed care contracts and create 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 monthly Excel reports and written appeals to address external underpayments.
• Track responses from MCOs and monitor recovery performance.
• Audit claim payments and identify discrepancies affecting accounts receivable.
• Collaborate with Revenue Cycle Directors to resolve emerging issues.
• Perform additional duties as assigned to support revenue cycle operations.

Job Requirements

• Minimum of 5 years of experience in health insurance and skilled nursing home billing.
• Proficiency in Medicare, Medicaid, and Managed Care billing and reimbursement processes.
• Experience with managed care claims and appeals processes for skilled nursing homes.
• Strong knowledge of billing systems, EOBs, remittance advice, and payment methodologies.
• Advanced skills in Excel, patient accounting systems, and provider portals.
• Excellent communication skills and ability to de-escalate conversations effectively.
• Detail-oriented with strong critical thinking and organizational abilities.
• Bachelor's degree in a related field is preferred.