Managed Care Specialist PRN

Peace River Center•Bartow, FL

27d

About The Position

To succeed as a Managed Care Specialist, you must be professional, cordial, friendly, and calm in stressful situations. Peace River Center is seeking a focused, detail-oriented person. The Managed Care Specialist. The Managed Care Specialist will complete all Managed Care/UR contract requirements for CSU inpatient length-of-stay approvals for clients in our CSU inpatient facilities. The MCS will complete all CSU inpatient financials, verifications, and assigned concurrent review clients for both BCSU and LCSU, as well as Carisk. The MCS will monitor, coordinate, and provide necessary verbal and written documentation as required by the payor. The MCS must have knowledge of the managed care system, including requirements and protocols, as well as verification of behavioral health benefits, precertification, utilization review, peer review, discharge review, and the appeals process. Understand the assessments, treatment planning, continuing care recommendations, diagnosis, and medications. Maintain good standing relationships with the team and insurance companies. General Expectations: In the performance of their respective task and duties, all employees are expected to conform to the following: Adhere to all PRC policies and Code of Conduct standards, and at all times exhibit all PRC’s Core Values. Perform quality work within deadlines with or without direct supervision. Interact professionally with other employees, customers, and vendors. Work independently, while understanding the necessity for communicating and coordinating work efforts with other employees and organizations, as required. Comply with all Center policies and procedures except those for which the employee gives notice of the need for reasonable accommodation and for which the Center can make such reasonable accommodation. An employee in this position must be able to react to change productively. Attends all scheduled work hours, meetings, training, and other center functions. Troubleshoot authorization discrepancies between PRC and the insurance companies. Provide training to staff on insurance and authorizations upon request. Responsible for inpatient financial data entries, including: Insurance verification and data entry for all CSU inpatients. Ensure that all episodes are completed. Enter accurate data entry as required. Attend daily CSU staff meetings for updates/status of all client admissions/discharges. Complete utilization and discharge reviews, and schedule peer reviews per payor requirements. Enter accurate data as required. Submit clinical records for appeals following the denial of authorization. Follow up on all clinical appeals and determine the final resolution for all appeals. Update the CSU payor log and distribute as required. Comply with no precert/LCD process. Register and discharge detailed data for CFBHN clients in the Carisk system. Essential Duties/Requirements/Activities: Ability to arrive/report to work on time and ready to work. Ability to abide by the company attendance policy. Ability to abide by principles of EEO compliance and a workplace of dignity and respect. Ability to work cooperatively in a group/team setting. Ability to show respect to others. Ability to take guidance and direction from supervisors. Ability to report to work with clean hygiene. Ability to adhere to the company /program dress code standards. Ability to professionally communicate with others. Ability to record minutes from meetings. Ability to keep information confidential. Ability to clearly discuss and train staff to discuss clinical/financial information with third-party payers, co-workers, and clients. Ability to encourage the treatment team to fully assess for presenting needs and assist in addressing needs. Ability to listen to and understand information and ideas presented verbally and in writing

Requirements

Must have strong organizational skills and be able to work independently.
Knowledge of facility systems and organization as they pertain to medical records and organization review.
Good customer-facing and phone skills.
Communication and interpersonal skills to develop relationships with clients, staff, providers, and payors.
Ability to arrive/report to work on time and ready to work.
Ability to abide by the company attendance policy.
Ability to abide by principles of EEO compliance and a workplace of dignity and respect.
Ability to work cooperatively in a group/team setting.
Ability to show respect to others.
Ability to take guidance and direction from supervisors.
Ability to report to work with clean hygiene.
Ability to adhere to the company /program dress code standards.
Ability to professionally communicate with others.
Ability to record minutes from meetings.
Ability to keep information confidential.
Ability to clearly discuss and train staff to discuss clinical/financial information with third-party payers, co-workers, and clients.
Ability to encourage the treatment team to fully assess for presenting needs and assist in addressing needs.
Ability to listen to and understand information and ideas presented verbally and in writing
High School diploma (GED)
2+ years in customer service.
2+ years in a business setting.
2+ years in a health care environment.
1+ year in communicating with external organizations.
Excellent written and verbal communication skills, including oral presentations.
Highly motivated, able to learn quickly, and prioritize multiple tasks.
Proficient in Word and Excel, and have the ability/willingness to learn other applications.
Excellent organizational skills, including setting up/maintaining files.
Proactive approach to problem resolution.
Familiarity with medical terminology.
Working knowledge of the healthcare revenue cycle process.
Strong interpersonal, communication, and persuasion/negotiation skills required to effectively interact with internal and external parties.
Must be able to follow detailed instructions.
Consistently exercises critical thinking skills or uses logic and reasoning to assess and resolve problems.
Quickly makes sense of, combines, and organizes information.
Consistently maintain a professional and approachable demeanor.
Able to work under pressure and meet stringent deadlines in a fast-paced environment.
Successfully alternates between two or more activities or sources of information.
Accepts responsibility and maintains a high level of accountability.
Handle unresolved inquiries/issues
Comply with Occupational Safety and Health Administration (OSHA) rules and regulations.
Must have reliable transportation—the ability to travel to both Bartow and Lakeland locations daily.

Nice To Haves

AA Degree a plus

Responsibilities

Complete all Managed Care/UR contract requirements for CSU inpatient length-of-stay approvals for clients in our CSU inpatient facilities.
Complete all CSU inpatient financials, verifications, and assigned concurrent review clients for both BCSU and LCSU, as well as Carisk.
Monitor, coordinate, and provide necessary verbal and written documentation as required by the payor.
Troubleshoot authorization discrepancies between PRC and the insurance companies.
Provide training to staff on insurance and authorizations upon request.
Responsible for inpatient financial data entries, including: Insurance verification and data entry for all CSU inpatients.
Ensure that all episodes are completed.
Attend daily CSU staff meetings for updates/status of all client admissions/discharges.
Complete utilization and discharge reviews, and schedule peer reviews per payor requirements.
Submit clinical records for appeals following the denial of authorization.
Follow up on all clinical appeals and determine the final resolution for all appeals.
Update the CSU payor log and distribute as required.
Comply with no precert/LCD process.
Register and discharge detailed data for CFBHN clients in the Carisk system.