Managed Care Specialist

Family HealthCare Network•Visalia, CA

2d•Onsite

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). This role involves primary IPA and Health Plan day-to-day interactions and activities, including addressing membership, credentialing, and referral-related issues, processing monthly membership attributions, analyzing membership trends, researching and drafting responses to Health Plan patient grievances, and reviewing requests for medical records. The specialist will also coordinate external party requests for EMR access and/or medical record retrieval, facilitate the scheduling of Health Plan contractual audit requests, and actively participate in Health Plan-based collaborative discussions, trainings, and Community Advisory Committee meetings. Additionally, the role requires producing and validating monthly reporting on various managed care activities, assisting with provider credentialing processes, and facilitating Health Plan and State Sponsored Program enrollments. Adherence to the Attendance and Absenteeism Policy and the ability to work at any FHCN location are also essential functions of this position.

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, and technical skills.
Have proof of completion of high school with a minimum overall GPA of 2.5 or completion of General Educational Development (GED) with a minimum overall score of 162.5.
Have a minimum of 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.

Nice To Haves

Preferred completion of an Associate's Degree program with a recognized major and a minimum cumulative GPA of 2.5
health care related knowledge frequently acquired through completion of a trade school, para-professional, or certificate type program.
If an individual has completed a degree at a higher level than required by the role and had a stronger GPA in that program, they may provide proof of GPA from that degree in lieu of the high school diploma.
Job duties require specific knowledge and training in general business.

Responsibilities

Primary IPA and Health Plan day to day interactions and activities, including addressing membership, credentialing, and referral related issues.
Processing and reviewing monthly membership attributions.
Analyzing and identifying membership trends for communication organization wide.
Researching, compiling, and drafting responses to Health Plan patient grievances.
Reviewing and submitting for approval, Health Plan requests for medical records.
Coordinating external party requests for remote EMR access and/or medical record retrieval.
Facilitating the scheduling of Health Plan contractual audit requests alongside FHCN staff and departments.
Active participation in Health Plan based collaborative discussions, trainings, and Community Advisory Committee based meetings.
Producing and validating monthly reporting related to the ongoing activities of the Managed Care department, including assigned membership trends, market shared analysis, Quality Improvement health plan initiatives, specialist network adequacy and improvement opportunities, provider credentialing based activities, and other reporting as determined by business needs.
Assisting the Credentialing Specialist(s) with the initial credentialing, reappointment, and hospital privileging process, as needed.
Facilitating the completion of Health Plan and State Sponsored Program enrollments through collection, assembly, and delivery of applications for final review and submission by the Managed Care Manager.
Adhering to the Attendance and Absenteeism Policy.
Ability to present to and work at any FHCN location, both at the beginning of a shift or during a shift, based on business need.
Other duties as assigned.