Managed Care Specialist

Overview

• Contribute to a healthcare organization's financial success by optimizing managed care billing processes and ensuring compliance with contracts.
• Collaborate with internal teams and external payers to resolve billing issues and appeals efficiently.
• Analyze managed care contracts to identify opportunities for maximizing reimbursement and enhancing revenue cycle performance.
• Prepare detailed reports and appeals to address denied or underpaid claims effectively.
• Utilize advanced billing systems and tools to monitor and audit claim payments for accuracy.
• Provide insights and troubleshooting to support organizational financial goals and operational efficiency.
• Stay updated on managed care contracts and reimbursement methodologies to ensure compliance.
• Contribute to process improvement initiatives to streamline operations and enhance productivity.

Key Responsibilities & Duties

• Analyze managed care contracts and develop spreadsheets for accurate payer submissions.
• Draft and submit appeals to Managed Care Organizations (MCOs) for denied claims.
• Collaborate with MCO payers to resolve payment errors and discrepancies promptly.
• Prepare monthly reports and track recovery performance from external payers.
• Audit claim payments to identify and address accounts receivable discrepancies.
• Work closely with Revenue Cycle Directors to address emerging issues and implement solutions.
• Perform additional duties to support revenue cycle operations and organizational goals.
• Ensure compliance with managed care contracts and reimbursement policies to maintain accuracy.

Job Requirements

• High school diploma or GED required; additional education is preferred.
• Minimum of 1 year of experience in health insurance or billing processes.
• Proficiency in Medicare, Medicaid, and Managed Care billing methodologies.
• Experience with claims and appeals processes in healthcare settings.
• Strong knowledge of billing systems, EOBs, and remittance advice.
• Advanced skills in Excel and familiarity with patient accounting systems.
• Excellent communication and problem-solving skills to address challenges effectively.
• Detail-oriented with strong organizational and analytical abilities to ensure accuracy.