Managed Care Coordinator coordinates utilization reviews of managed care contracts using established guidelines and processes. Ensures all clinical operations comply with Medicare and Medicaid guidelines and other managed care policies. Being a Managed Care Coordinator communicates with physicians, discharge planners and others to process referrals, authorization for services, and capture data related to utilization. Maintains managed care contracts and information databases and prepares reports. Additionally, Managed Care Coordinator typically requires an associate degree in nursing. Typically reports to a supervisor or manager. Typically requires Registered Nurse (RN). The Managed Care Coordinator has gained full proficiency in a broad range of activities related to the job. Independently performs a wide range of complex duties under general guidance from supervisors. To be a Managed Care Coordinator typically requires 5-7 years of related experience. (Copyright 2024 Salary.com)
MANAGED CARE SPECIALIST JOB SUMMARY
A Managed Care Specialist reviews all hospital / physician payment variances and prepares and files appeals or otherwise works with payer to ensure full payment according to contract for services provided.
Identifies trends with third party payers as well as in-house activity that results in payment variances and offers opportunities for process improvement.
Works closing with Billing / Follow Up, Case Management, and Patient Access.
MANAGED CARE SPECIALIST JOB SPECIFICATIONS
or equivalent experience. Experience in hospital / physician billing, Managed Care contracts, customer service, insurance benefit verification and precertification preferred.
KNOWLEDGE : Requires thorough knowledge of insurance company processes and insurance contract reimbursement methodology as well as fundamental understanding of hospital / physician fee schedules and how they apply contractually.
Requires in depth knowledge of medical coding affecting adjudication of UB-04 claims, including; APC, ICD, CPT, HCPCS, DRG, and revenue code structures.
SKILLS : Requires analytical problem solving skills to organize / assess information based on data collected; Critical thinking, judgment, and decision making skills are essential;
Requires excellent computer skills in various information systems; Requires excellent verbal, mathematical, and written communication skills.
ABILITIES : Requires an ability to work independently and gain assistance from multiple sources; Requires an ability to integrate information and make decisions;
Requires an ability to provide consistent, effective follow-up and documentation; Requires an ability to effectively with departments in a team environment.
Ability to communicate professionally and thoroughly with staff, patients, insurance companies, business partners and other parties.
Competitive Pay and Benefits
Health, dental and vision insurance
Retirement plan with matching
Flexible Savings Account (FSA)
Disability insurance
Life Insurance
Paid sick time
Paid time off
Paid training
Referral program
Tuition reimbursement
Employee Assistance Program
PI238194793
Compensation Information :
$0.0 / - $0.0 /
Starting At : 0.0
Up To : 0.0
Last updated : 2024-03-22
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