Managed Care Specialist

Overview

• Support managed care operations by overseeing billing, collections, and claims resolution processes with a focus on accuracy and efficiency.
• Collaborate with payers to address discrepancies, underpayments, and denied claims, ensuring optimal reimbursement outcomes.
• Utilize advanced billing systems to monitor recoveries, audit payments, and identify accounts receivable issues.
• Prepare detailed reports, appeals, and project spreadsheets to support claims resolution efforts.
• Communicate effectively with internal teams and external payers to ensure seamless resolution of claims disputes.
• Work closely with leadership to align managed care operations with organizational goals and compliance standards.
• Maintain meticulous tracking of managed care responses and outcomes to enhance operational transparency.
• Ensure adherence to managed care contracts, payment methodologies, and regulatory requirements.

Key Responsibilities & Duties

• Analyze managed care contracts to identify discrepancies and develop actionable solutions.
• Draft and submit appeals and reconsiderations to managed care organizations for claims resolution.
• Generate comprehensive monthly reports and appeals to support claims dispute resolution.
• Track and document managed care organization responses to ensure timely resolution of claims.
• Utilize billing systems to audit payments, monitor recoveries, and address accounts receivable issues.
• Collaborate with leadership to address emerging issues and align operations with strategic goals.
• Ensure compliance with managed care contracts and payment methodologies.
• Provide detailed tracking and documentation to support operational transparency and efficiency.

Job Requirements

• Minimum 1 year of experience in health insurance or managed care billing.
• Proficiency in Medicare, Medicaid, and managed care reimbursement processes.
• Experience with claims and appeals processes in healthcare settings.
• Strong skills in Excel, patient accounting systems, and provider portals.
• Ability to analyze EOBs, remittance advice, and managed care contracts effectively.
• Excellent communication skills for effective collaboration and dispute resolution.
• Detail-oriented with strong organizational and critical thinking abilities.
• High School Diploma/GED required; Bachelor’s Degree in a related field preferred.