Managed Care Specialist

Job Description

Job Description

General Job Purpose

The Managed Care Specialist is responsible for the identification, tracking, and trending of payment variances. Additionally, the Specialist will provide root cause analysis by payor, working with the payors and key stakeholders to resolve those variances improving financial performance. The Specialist will work with key stakeholders to improve collections and change payer behavior while improving overall communication to successfully execute departmental and company goals.

What You Will Be Working On

Performance

• Responsible for the contract build in the EMR and serves as the subject matter liaison for any external contract variance tools or systems

• Identify, track, trend, and provide root cause of payor variances

• Prepare necessary documentation that allows for the collections of those variances

• Educate key stakeholders on actions needed to eliminate variances, when variances are due to internal processes i.e. coding, billing etc.

• Assist Provider Enrollment with analytics needed, trending payor response times, application denials/delays by payors

• Work with leaders to identify areas of revenue loss by service/CPT, identifying lesser-of

• Review and monitor contractual allowance calculations and variances in expected reimbursement. Identify origin of variance (under/over payment) or modeling discrepancies and perform routine root cause analysis to identify system and/or contract modeling errors

• Provide ongoing support and tools for internal and external customers related to MVP's Managed Care

• Collaborate with key stakeholders to ensure appropriate facility/ASC credentialing needs are addressed

• Analyze data, providing trending and identify root cause within Managed Care and Credentialing

• Resolution and collection of variances by making calls to the payer, appeals, portal appeals, written appeals, payor calls etc.

• Collection and maintenance of payer correspondence and bulletins. Effectively communicating updates/changes to internal customers

• Develop SOPs for consistency and alignment with company goals

• Perform other duties as assigned

Communication

• Communicate effectively with all stakeholder groups to review performance, discuss issues impacting financial performance, share information and key updates, and provide education:

- Payor

- Internal team members/leadership

- Third parties and vendors

WHAT WILL MAKE YOU AWESOME

• Exemplary working knowledge and interpretation of provider and payor contracts and fee schedules to determine valid variances

• Excellent written and verbal communication skills

• Highly organized, dependable, and focused on quality and service

• Self-directed, metrics minded, and unafraid of challenging the status quo

• Demonstrated teamwork skills and the ability to work with different teams, entities

• Proficiency using Microsoft Office, such as Outlook, Word, Excel, and PowerPoint

• High ethical standards

• Ability to work with a high attention to detail

WHAT YOU KNOW:

To be successful in this role you will have the following experience or knowledge:

• Bachelor's degree in finance or business-related a plus; or commensurate experience

• 5+ years in payer relations/contracts/fee schedules aiding in payment variance identification and resolution or related industry experience