Managed Care Specialist

• Identify and ensure that all available health insurance resources are utilized to offset medical expenses incurred by clients of the agency;
• Compile and review documents required for managed care, insurance, Medicaid, Medicare, and other payer contracts;
• Assist in internal and external insurance and billing audits by gathering requested documentation, ensuring compliance with organizational policies and payer requirements, responding to audit inquiries, and assisting with the implementation of corrective actions as needed;
• Record and maintain accurate contract information and payer communications, appeals, authorizations, and claim activity within the electronic health record and billing systems;
• Submit, monitor for compliance, and reconcile electronic claims to managed care organizations and third-party payers;
• Provide support to billing services, correct errors, and track payments;
• Assist in investigating, resolving, and appealing denied or rejected claims by identifying root causes and coordinating corrective actions with clinical and billing staff;
• Communicate with insurance representatives when required regarding claim status, payment discrepancies, prior authorizations, and reimbursement issues;
• Review explanation of benefits (EOBs) remittance advice and payment reports to identify billing discrepancies and initiate corrections;
• Collaborate with clinical, registration, and billing staff to resolve documentation deficiencies that impact claim submission and payment;
• Assist in generating and analyzing reports related to denials, authorizations, aging accounts receivable, payer trends, and reimbursement performance;
• Compile and review data to measure performance, clinical outcomes, and identify problems and gaps;
• Assist in developing and implementing billing workflow improvements that enhance efficiency, compliance, and revenue cycle performance;
• Perform other related duties as required.

• Good knowledge of Medicaid/ Medicare/Managed Care and insurance policies and procedures for reimbursement for behavioral health services; good knowledge of HIPAA and Corporate Compliance regulations; working knowledge of NYS OMH and OASAS regulations.
• Working knowledge of medical terminology, insurance policies and managed care concepts; strong analytical and problem solving abilities; ability to perform electronic billing accurately; ability to collect, organize and review data.
• Ability to communicate effectively both verbally and in writing; ability to write clear and accurate reports and maintain records as required; ability to enter, retrieve and interpret information in central computerized systems; ability to establish and maintain effective relationships with clients, staff and providers; ability to work independently; ability to manage multiple priorities and meet deadlines; ability to exercise initiative and tact.

• Graduation from high school or possession of a high school equivalency diploma; AND
• (a)  Graduation from a regionally accredited or New York State registered college with an Associate's Degree or higher and one (1) year of full-time or its part-time equivalent experience in managed care, insurance or healthcare business operations; or
• (b)  Three (3) years of experience as defined in (a) above.

Otsego County is a destination with small-town charms and world-class attractions including the National Baseball Hall of Fame & Museum, a must-see for fans of the game and the ultimate homage to America's Pastime. Discover fine, folk, and Native American art at Fenimore Art Museum, acclaimed and varied performances at the Glimmerglass Festival, craft beer at Brewery Ommegang and the Cooperstown Beverage Trail, plus fresh cider from the Fly Creek Cider Mill, great restaurants, four-season events, and outdoor fun.