JOB SUMMARY
The Managed Care Specialist is responsible for the ongoing implementation and improvement of contract enforcement processes when contract violations related to Prompt Payment have escalated to require legal intervention. This position works with various stakeholders (Managed Care, Central Business Services, Legal Counsel) to ensure a coordinated process with measurable outcomes.
ESSENTIAL FUNCTIONS OF THE ROLE
• Serves as primary contact for Central Business Services (CBS), the Transplant Business Unit, Legal and Managed Care for managed care claims management escalated for legal follow up.
• Oversees the development, implementation and maintenance of the Prompt Pay Database.
• Manages claims identification and review processes: coordinates data pulls; coordinates request for claim documents; review and evaluate all documents; assesses each claim against applicable contract.
• Serves as the primary contact for negotiations with managed care payors on individual claims in Prompt Pay Database.
• Represents the organization as a Fact Witness and Corporate Representative in depositions, hearings and trials, under oath.
KEY SUCCESS FACTORS
• Ability to establish and maintain effective professional relationships across organizational lines.
• Ability to develop and implement short and long range organizational goals, objectives, strategic plans, policies, and operating procedures.
• Ability to balance multiple demands and respond to time constraints
• Ability to understand, optimize and document complex processes.
• Must be able to communicate thoughts clearly; both verbally and in writing.
• General computer skills, including but not limited to: using required software applications, data entry, information security, electronic medical documentation, hand held scanning and email.
• knowledgeable regarding managed care concepts, financial analysis, insurance payment systems and process, legal procedures and processes, IT systems, and current legislation at both the state and federal level as applicable to contracts and processes.
• Extensive interpersonal and communication skills to conduct education programs and to effectively interact with both internal and external personal including physicians, attorneys, all levels of management, employers, managed care organizations and other providers.
• Ability to lead and self-manage, adapting easily to changing conditions, work priorities, and work responsibilities.
• Dispute resolution and conflict management skills.
• Proficient in all Microsoft Products.
BENEFITS - Our competitive benefits package includes the following:
• Immediate eligibility for health and welfare benefits
• 401(k) savings plan with dollar-for-dollar match up to 5%
• Tuition Reimbursement
• PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level
QUALIFICATIONS
• EDUCATION - Bachelor's
• EXPERIENCE - 2 Years of Experience