A Managed Care Specialist works for the healthcare sector and takes responsibility for verifying insurance coverage. While duties vary from setting to setting, the following are certain core duties seen on the Managed Care Specialist Resume – working directly with patients; referring patients to specialists; keeping track of referral status; obtaining authorization on behalf of patients from managed care facilities; working with patient’s physicians to clarify referrals, acting as liaison among insurance company, customer operation staff; and patient billing staff; and addressing patient concerns with regards to health insurance coverage.
Employers prefer to hire those with at least a high school diploma or GED. Companies hire employees, but often candidates with prior work experience are preferred. These specialists must be able to work in a team environment, possess basic computer skills; and excellent interpersonal skills and communication skills. knowledge of using relevant software is also crucial for this role.
Objective : As a Managed Care Specialist, responsible for providing overall clerical support for the Clinical Services Department. Experience including all support for chart maintenance and retention (including filing, scanning, and record processing into the case management and/or scanning database), employee record maintenance and filing, employee payroll activities, maintenance of Excel logs for employee personal time, report generation, and data entry/authorization entry as dictated by unit workflows.
Skills : MS Office, Effective Communicator, Works Well With Others.
Description :
Assisted in developing memos, a training Webinar, and reviewer procedure forms (SharePoint, Wufoo, and reviewer checklists) for the LTSS initiative Quality Improvement in Long Term Services and Supports (QuILTSS).
Created and maintained a tracking spreadsheet of all reviews.
Created and maintained a tracking spreadsheet of reconsideration requests, as well as participated in the reconsideration process.
Provided detailed feedback for corrections and training to the facilities.
Assisted in the creation of the new and updated Excel spreadsheet to be used to submit data for this program.
Performed utilization reviews of providers in the DIDD waiver program.
Managed third-party payer contracts and Provider Enrollment and keeps files up to date.
Recommended new strategic managed care opportunities to the CFO.
Experience
2-5 Years
Level
Junior
Education
High School Diploma
Managed Care Specialist Resume
Headline : As a Managed Care Specialist, responsible for contract assessment, negotiation, financial analysis, problem-solving, revenue modeling, and advanced analytics. Experience in work with the Business Office Team to monitor changes in payment schedules, changing reimbursements, changes in healthcare delivery models, and expiration dates of payer contracts. The Managed Care Specialist will act as a liaison between the hospital and third-party payers.
Skills : Collections, Medical Billing, Supervisor, Customer Service, Data Entry, Coding, Medical Terminology, Medical Records, Faxing, Excel, Meditech, Patient Scheduling.
Description :
Created and sent Appeals to payers.
Created spreadsheets through excel for bulk appeal review.
Reviewed EOB's for correct payments. Maintained proper aging of accounts receivable.
Performed precise audits of patient accounts to ensure accuracy of charges, payments, and adjustments.
Monitored payments to ensure payers conform to agreed fee schedules.
Acquired insurance authorization for procedures and tests ordered by attending physician and hospital.
Coordinated negotiation and implementation of commercial contracts and payers.
Monitored and communicated changes in payment schedules, reimbursements, and expiration dates of third-party payer contracts.
Experience
5-7 Years
Level
Executive
Education
Diploma
Managed Care Specialist Resume
Headline : Service-oriented Managed Care Specialist with a 20-year background in the Central Business Office. Core competencies include PC literate, including Microsoft office products, ability to work in a team environment, and a strong work ethic as well as excellent communication and time management skills. Handles tasks with accuracy and efficiency.
Skills : Critical Thinking, Judgement And Decision Making, Coordination, Monitoring, Complex Problem Solving, Negotiation, Time Management.
Description :
Received payments and post amounts paid to customer accounts.
Answered customer questions regarding problems with their accounts.
Contacted insurance companies to check on the status of claims payments.
Appealed to the payers for correct reimbursement according to contracts agreement.
Appropriately and correctly identified errors and refiled denied/reject claims as they were received.
Thoroughly investigated past due claims and minimized the number of unpaid accounts, Work zero pays, and correspondence daily.
Provided insurance companies with the requested information to facilitate payment Maintain accounts to 30-90 days.
Developed and administered the managed care contracts for the facility by working closely with clinicians and processing referrals.
Experience
5-7 Years
Level
Executive
Education
High School Diploma
Managed Care Specialist Resume
Headline : Seeking a Medical Assistant, LPN/RN to function in the Managed Care Specialist role. Responsible for coordinating all patient referrals to specialists & outside testing facilities.
Skills : Medical Billing, Problem Solving, Organized.
Description :
Developed and delivered managed care education to Northeast Ohio sales representatives, leading to award-winning sales results.
Collaborated and implemented smoking cessation education programs with Northeast Ohio, health plans, and employer wellness programs.
Implemented an Inquiry and Analysis of best practices amongst Managed Care Representatives.
Planned, organized, and facilitated GSK National Managed Care Representative meeting, bringing together three managed care groups to define and unify their roles.
Reviewed and interpreted remittances to determine appropriate actions that need to be taken on denied claims based on basic proficiency in diagnosis coding (ICD-9) and procedural coding (CPT) may be resubmitted for coding correction.
Generated collections letters and follow up on delinquent account balances.
Monitored the performance of managed care contracts to ensure accurate claims processing; including the level of underpayments and overpayments by providers.
Created and presented financial models pertaining to managed care contracts.
Experience
5-7 Years
Level
Executive
Education
GED
Managed Care Specialist Resume
Objective : Managed Care Specialist with 2+ years of supporting contract development, implementation, and ongoing relationship management with payors. and also serving as the primary contact within ProHEALTH for all service issues related to contract operations including credentialing, fee schedules, and regulatory compliance.
Skills : Significant Medical Billing, Medical Collections, Communication.
Description :
Researched and effectively resolved issues through knowledge of medical billing practices.
Reviewed all invoices and made the necessary financial transfers.
Maintained knowledge of consumer credit regulations for self-pay accounts.
Contacted payers for the status of unpaid claims.
Maintained knowledge of third party payer regulations for Managed Care, Medicare, and Medicaid accounts.
Appealed low payment claims to maximize reimbursement.
Recommended account adjustments for a bad debt write-off, contractual allowances, and discounts.
Served as an internal and external liaison to resolve managed care issues, assist with provider communications, and perform claims research to maintain positive relationships with providers and payers.
Managed client, provider and payer support calls.
Experience
2-5 Years
Level
Junior
Education
G.E.D
Managed Care Specialist Resume
Summary : Highly qualified Managed Care Specialist with experience in the industry. Enjoy creative problem solving and getting exposure on multiple projects, and I would excel in the collaborative environment on which your company prides itself.
Skills : MS Office, Typing, Billing & Collection, Management.
Description :
Corresponded with insurances, physician's offices, and patients coordinating referrals for medical visits and treatments.
Recorded referral activity electronically and also in the hard copy medical chart.
Researched patient insurance for eligibility and benefits.
Resolved Tenn Care eligibility appeals Assist clients with insurance concerns and claims Maintain accurate data of all assigned cases Accomplishments.
Created and delivered education material regarding contracts and implications.
Informed CFO and Business Office Director of any changes in reimbursement or regulatory requirements.
Ensured all required processes related to strategic pricing, legal reported, and communication are deployed to maximize contract performance and yield.
Experience
7-10 Years
Level
Management
Education
Master's In Management
Managed Care Specialist Resume
Objective : As a Managed Care Specialist, responsible for background in payer and provider relations, have superior organizational skills, be adept in the preparation of presentations, participating in & leading presentations, taking and distributing accurate meeting notes or minutes & monitoring or reporting status of department initiatives.
Skills : Case Management, MS Office, Customer Service.
Description :
Worked as an ARAD Technician with the Bureau of Tenncare in the Eligibility Operations Group; responsibilities included reading and reviewing applications for Long Term Care assistance as well as applications from the federal healthcare marketplace for Medicare coverage.
Screened applications and registered them for processing.
Facilitated expedited processing of special requests from program managers and processors for an application that needs to be re-registered or registered immediately within 24 hours of receiving them.
Received emails with requests, screened and researched the case, and then assigned them to ARAD technicians for immediate processing when possible.
Completed applications for payer contracts and analyzes contract offers from payers to ensure offerings are competitive within the market.
Reviewed contract language for financial, legal, and operational impact and to ensure compliance with State and Federal Regulatory Agencies.
Ensured billing practices are within compliance by staying up to date on changes within the managed care market.
Experience
2-5 Years
Level
Executive
Education
BA In Business
Managed Care Specialist Resume
Objective : Detailed-orientated Managed Care Specialist professional with the ability to successfully manage full lifecycles of client meetings and programs. Highly organized with excellent interpersonal and customer service skills, problem-solving, thrives under pressure, is an enthusiastic and dedicated employee with uncompromised integrity, strong work ethic.
Skills : MS Office, Organization, Communication, Written Communication, Verbal Communication.
Description :
Used computers for various applications, such as database management or word processing.
Answered telephones and give information to callers, take messages, or transfer calls to appropriate individuals.
Created, maintained, and entered information into databases.
Managed paper or electronic filing systems, recording information, updating paperwork, or maintaining documents, correspondence, or other material.
Completed forms in accordance with company procedures.
Scheduled and confirmed appointments for patients.
Opened, read, routed, and distributed incoming mail or other materials and answer routine letters.
Preauthorized medical procedures and completed referrals for medical providers.
Experience
2-5 Years
Level
Executive
Education
High School Diploma
Managed Care Specialist Resume
Headline : Experienced professional with over 14 years of administrative, management, training, and problem-solving skills seeking a Managed Care Specialist position to support a growing organization and its leaders with an emphasis on excellence, community involvement, and progress.
Skills : Microsoft Office, Meditech, Customer Service, Large data sets analysis, Problem Solving, Fluent In English.
Description :
Researched, compiled, analyzed, and summarized data for routine and/or special projects or reports.
Supported the benefits department in the planning and development of annual enrollment activities.
Maintained an ongoing effort to determine and maintain equity with current benefit trends, programs, and legislative requirements.
Compiled and interpreted data related to benefits activity.
Coordinated interdepartmental functioning.
Responsible for providing credentialing verification services of licensed personnel; schedule patient care services to ensure quality outcome; manages functions within the home health care agency by providing strategic planning and coordination to ensure quality care.
Prepared monthly metrics as required or directed.
Experience
5-7 Years
Level
Executive
Education
BS In Manager
Managed Care Specialist Resume
Objective : Seeking a Managed Care Specialist with an outstanding career opportunity that will offer a rewarding work environment along with a winning team that will fully utilize management skills.
Skills : Medical Terminology, Strong Medical Terminology, Effective Communication Skills.
Description :
Performed hospital account audits for appropriate billing information, appeals, rebills, adjustments, and insurance follow up.
Reviewed account to ensure all accounts are paid according to hospital contract.
Reviewed and updated the plan ID's then patient/payor demographic information.
Ensured all work efforts are in compliance with company policy and procedures.
Responsible for maintaining collaborative relationships, and being committed to excellence.
Responsible for maximum productivity in the recovery of delinquent accounts receivable.
Documented all collection activity, maintains and organizes unit, and responds to all correspondence, communication, and/or verbal inquiries from all relevant parties.
Maintained appropriate records, files, and documentation.
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