Managed Care Technician

Family HealthCare Network•Visalia, CA

44d•Onsite

About The Position

The Managed Care Technician is responsible for contributing towards the efforts of the Managed Care department through support of managed care contracting requirements, the provider and site enrollments with payors, and maintaining IPA relationships. This role involves primary day-to-day interactions and activities with IPAs and Health Plans, addressing membership, credentialing, and referral-related issues. It also includes processing and reviewing monthly membership attributions, analyzing membership trends, and researching/drafting responses to health plan grievances. The technician will also coordinate external party requests for EMR access and medical record retrieval, facilitate the scheduling of health plan contractual audits, and actively participate in health plan-based collaborative discussions and meetings. A key responsibility is producing and validating monthly reporting on assigned membership trends, market share, quality improvement initiatives, network adequacy, and provider credentialing. The role also assists with provider credentialing and reappointment, facilitates health plan and state sponsored program enrollments, and may be responsible for provider hospital privileges and enrollment with various payors. This includes collecting, organizing, verifying, and maintaining all required documentation, monitoring application status, and processing routine payer updates. Adherence to the Attendance and Absenteeism Policy and the ability to work at any FHCN location are also essential.

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.
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.
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.
Regularly required to sit and use repetitive hand movement to type and grasp.
Frequently required to stand or walk.
Must occasionally lift and/or move up to 20 pounds.

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.

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 share 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 with the provider initial credentialing and reappointment process, as needed.
Facilitating the completion of Health Plan and State Sponsored Program enrollments through the collection, assembly, and delivery of applications for final review and submission.
If assigned, complete provider hospital privileges by preparing initial and reappointment applications; verifying required credentials and supporting documentation; monitoring application status; serving as the liaison between providers, hospitals, and internal departments; and maintaining accurate records.
If assigned, responsible for enrollment with health plans, Medi-Cal, Medicare, and other payors.
Collect, organize, verify, and maintain all required credentialing and enrollment documentation; prepare provider enrollment applications to health plans, IPAs, Medicare, Medi-Cal, and other payers.
Monitor application status, follow up on outstanding requirements and documentation, and maintain accurate, complete, and up-to-date credentialing and enrollment records.
Process routine payer updates for new and terminated providers, new locations, changes in office hours, and other demographic, practice, or provider information changes.
Responsible for 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.