Managed Care Job Description
Managed care
provides analysis of business to the Director Managed Care and SVP Managed Care weekly, monthly as needed.
Managed Care Duties & Responsibilities
To write an effective managed care job description, begin by listing detailed duties, responsibilities and expectations. We have included managed care job description templates that you can modify and use.
Sample responsibilities for this position include:
Verify the providers
Check benefits
Determine if a referral is necessary before setting up the authorization
Answer authorization requests via phone or fax
Verify the provider, check benefits, and determine if a referral is necessary
Set up authorizations
Perform review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients
Handle initial screening from physicians/members via incoming calls or correspondence based on workflows, and under the oversight of clinical staff
Prepare, document and route cases in appropriate system for clinical review
Initiate call backs and correspondence to members and providers to coordinate and clarify benefits
Managed Care Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Managed Care
List any licenses or certifications required by the position: CPR, BLS, AHA, CCM, GOLD, ACM, CM, CPCS, VNSNY, EPIC
Education for Managed Care
Typically a job would require a certain level of education.
Employers hiring for the managed care job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Master's Degree in Finance, Business, Education, Accounting, Business/Administration, Healthcare, Nursing, Social Work, Management, Counseling
Skills for Managed Care
Desired skills for managed care include:
Market trends
CQI concepts when performing all aspects of the job
Customer base competition
Health care and managed care products
Industry dynamics
Network Management concepts
Company's general business principles
Medical terminology
Medicare
TRICARE program
Desired experience for managed care includes:
Displays keen public-speaking ability
Initiate call back or correspondence to Physicians/Members to coordinate/clarify case completion
Review professional medical/claim policy related issues or claims in pending status
Handle initial screening for pre-certification requests from physicians/members via incoming calls or correspondence
Authorize services based upon scripts or algorithms used for pre-review screening
Demonstrate ability to analyze information, research problems, and determine and implement solutions
Managed Care Examples
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Managed Care Job Description
Job Description Example
Our innovative and growing company is looking to fill the role of managed care. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for managed care
- Coordinate payor enrollment and re-enrollment for the providers in the enterprise by working closely with providers and various internal and external departments to ensure rapid and accurate credentialing for network participation (Credentialing/Linking)
- Maintain CAQH profiles for all participating providers to ensure accounts are readily available for payors to access for re-credentialing
- Implement VISTAR Payor Enrollment Portal
- Review and respond to payor settlement offers and assist providers/practices in obtaining out of network authorizations and/or single case agreements
- Manage access to payor portals and serve as security officer for those portals
- Create and maintain insurance grids for all practices and communicate any changes in participation status to providers/office staff in a timely fashion
- Manage group/provider/locations in practice management systems to support scheduling, charge capture, billing and EHR
- Assist in Managed Care negotiations through financial analysis, rate reviews and other duties as defined by the Manager
- Conduct regular reporting to identify any shortfalls in reimbursement so as to maximize revenue/profitability
- Network and coordinate the sharing, receipt, and/or update of information among various internal departments and the insurance plans
Qualifications for managed care
- Ability to handle customer contact in a courteous and professional manner
- Knowledge of Microsoft Excel, Microsoft Power Point and Outlook software
- Maintain direct knowledge of industry changes affecting the credentialing process and/or impair reimbursement
- Provide clear and concise communication of detailed information in both verbal and written form
- Maintain up to date extensive knowledge of the requirements by governmental payers, managed care, and other provider networks
- Accurately enter, update and audit one's own API clocking transactions (time card) including benefit time
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Managed Care Job Description
Job Description Example
Our innovative and growing company is looking for a managed care. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for managed care
- Handles initial screening for pre-certification requests from physicians/members
- Initiates call backs and correspondence to members and providers to coordinate and clarify benefits
- Perform review of service requests
- Handle initial screening for pre-certification requests from physicians/members
- Timely and accurate payment processing
- Formulary validation
- Data scrubbing
- Adjudicating payments in accordance with contracted terms and conditions
- Handle initial screening for pre-certification requests from physicians/members via incoming calls or correspondence based on scripts and workflows, and under the oversight of clinical staff
- Downloads, scans and catalogues all hospital and client-related documentation (contracts, medical records, UB04s, EOBs, ID Cards)
Qualifications for managed care
- 1+ year of Customer Service or Medical Support experience
- 1-2 years of customer service or medical support-related experience
- MTF Support.Works collaboratively with HSMs/HSSs and MTF personnel to manage relationships and facilitate resolution of issues within assigned HSAs
- Communication and Relationships.Develops and fosters relationships that enable the associate to identify and meet customer needs
- Reporting and Documentation.Utilizes designated information systems to track issues and resolution status
- 1-2 years of customer service or medical support-related position
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Managed Care Job Description
Job Description Example
Our company is searching for experienced candidates for the position of managed care. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for managed care
- Responds to special project needs as dictated by ManagementAdheres to all company policies and procedures including, but not limited to those identified within the Standards of Business Conduct and the Employee Handbook, as may be amended from time to time
- Performs Managed Care, Reimbursement analytical projects to support the field in optimizing reimbursement
- Performs special projects related to the financial and operational functions of the service line
- All referrals and pre-authorizations that need to be generated
- Responding promptly to those patients in the Physician offices needing immediate referrals otherwise processes within 24 hours
- Keeping the managed care information up-to-date for all Physicians and providers for all practices
- Tracking referrals that are "in process" with utilization management / pre-authorization
- Maintaining spreadsheets for various accounts
- Assisting with other duties, including the payables in the department
- Coordinating transitions of care for all inpatient ( planned and unplanned) admissions and discharges
Qualifications for managed care
- Minimum seven years progressive healthcare management experience in a managed care environment at the multi-state/multi-site level
- 3 year Home Care or Case Management with knowledge of home and community base services and 1-2 years geriatric case management
- May require extended periods of sitting
- Processing all newly enrolled cases according to established workflows and maintains integrity of members’ files
- Receiving and processing initial requests and inquiries regarding pre-authorization of services/supplies
- Coordinating and providing service authorizations to vendors regarding Personal Care Worker, Transportation services, PERS, DME supplies and all other covered services
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Managed Care Job Description
Job Description Example
Our company is growing rapidly and is searching for experienced candidates for the position of managed care. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for managed care
- Maintain and track laws and regulations, contract documentations, amendments, and various compliance measures pertaining to Commercial, Medicare and Medi-cal managed care
- Develop policies, procedures, and processes to comply with federal program regulations and any applicable state regulations pertaining to Commercial, Medicare and Medi-Cal managed care
- Provide guidance to various departments regarding compliance issues and implementation of new compliance requirements with respect to regulatory and contract language for Commercial, Medicare and Medi-Cal managed care
- Ensuring timely disenrollment of HF/MAP members as per DOH regulations
- Answering routed Automatic Call Distributor (ACD) / Interactive Voice Response (IVR) Calls
- Performing review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients
- Handling initial screening for pre-certification requests from physicians/members via incoming calls or correspondence based on scripts and workflows, and under the oversight of clinical staff
- Preparing, documenting and routing cases in appropriate system for clinical review
- Initiating call backs and correspondence to members and providers to coordinate and clarify benefits
- Reviewing professional medical/claim policy related issues or claims in pending status
Qualifications for managed care
- Case / Care Management background
- Minimum three (3) years acute care nursing experience
- Minimum one (1) year utilization management, case management, geriatric nursing, home care, and/or discharge planning experience
- 10+ years healthcare management experience in a managed care/health provider environment
- Able to guide, lead and oversee staff while providing clear and accurate information regarding tasks, assignments, policies
- Clinical protocol development
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Managed Care Job Description
Job Description Example
Our company is growing rapidly and is looking for a managed care. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for managed care
- Coordinates with hospital care management team to facilitate the patient’s individual needs
- Actively participates in daily care management rounds, interdisciplinary team meetings and encourages multi-discipline group discussions
- Achieve and exceed the annual sales targets within the Managed Care Program (MCP)
- Define and propose a sales action plan for MCP in each Regional
- Continuously look for new customer acquisition and expanding MCP within existing customers
- Develop and maintain a highly effective ISP (Independent Service Provider) network
- Management and Conduct PPE (personnel protective equipment) Assessments
- Provide technical training and support when needed to distributors and regional sales force
- Ownership of product and technical support for Asset Tracking Software (FIRST)
- Visit largest end-users to identify needs and convert them to HFR products and MCP services
Qualifications for managed care
- MTM benefit design
- Network contracting
- Network training and support
- Bachelors degree in pharmacy required, Doctor of Pharmacy degree preferred from an ACPE-accredited College of Pharmacy
- Eligible for pharmacist licensure in Iowa
- Ability to manage multiple priorities while maintaining a strong attention to detail