Managed Care Specialist

Family HealthCare Network • Visalia, CA

3d • $22 - $30

About The Position

The Managed Care Specialist is responsible for contributing towards the efforts
of the Managed Care department through support of managed care contracting
requirements, the provider credentialing process, and maintaining IPA
relationship(s).

Requirements

• Possesses work-related skills at a higher level than completion of high school, including formal written and verbal communications skills, computational and computer skills, mathematical, technical or health care related knowledge frequently acquired through completion of a trade school, para-professional, or certificate type program.
• Job duties require specific knowledge and training in general business.
• Two years of healthcare administration or relevant experience.
• Ability to prepare more complex documents in Microsoft Word, including creating tables, charts, graphs and other elements.
• Ability to use Microsoft Excel to review and compile data, including the use of formulas, functions, lookup tables and other standard spreadsheet elements.
• Ability to create basic presentations in Microsoft PowerPoint.
• Job duties require the compilation of information prepared in effective written form, including correspondence, reports, articles or other documentation.
• Effectively conveys technical information to non-technical audiences.

Responsibilities

• Responsible for primary IPA and Health Plan day to day interactions and activities, including, but not limited to: 1. Addressing membership, credentialing, and referral related issues. 2. Processing and reviewing monthly membership attributions. 3. Analyzing and identifying membership trends for communication organization wide. 4. Researching, compiling, and drafting responses to Health Plan patient grievances. 5. Reviewing and submitting for approval, Health Plan requests for medical records. 6. Coordinating external party requests for remote EMR access and/or medical record retrieval. 7. Facilitating the scheduling of Health Plan contractual audit requests alongside FHCN staff and departments. 8. Active participation in Health Plan based collaborative discussions, trainings, and Community Advisory Committee based meetings.
• Responsible for producing and validating monthly reporting related to the ongoing activities of the Managed Care department, including but not limited to: 1. Assigned membership trends and market shared analysis 2. Quality Improvement health plan initiatives 3. Specialist network adequacy and improvement opportunities 4. Provider credentialing based activities 5. Other reporting as determined by business needs
• Assists the Credentialing Specialist(s) with the initial credentialing, reappointment, and hospital privileging process, as needed.
• Facilitates the completion of Health Plan and State Sponsored Program enrollments through the collection, assembly, and delivery of applications for final review and submission by the Managed Care Manager.
• Other duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED