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 : Dedicated Managed Care Specialist with 2 years of experience in contract management and payer relations. Proficient in analyzing reimbursement models, optimizing service delivery, and enhancing operational efficiencies. Adept at collaborating with multidisciplinary teams to ensure compliance with regulatory standards and improve patient outcomes. Committed to leveraging data-driven insights to support healthcare initiatives.
Skills : Microsoft Office Suite, Strong Interpersonal Skills, Care Coordination, Patient Advocacy
Description :
Facilitated communication between healthcare providers and insurance companies.
Created and maintained a tracking spreadsheet of all reviews to enhance reporting accuracy.
Facilitated the reconsideration process by managing request tracking spreadsheets.
Reviewed and processed prior authorization requests for medical services.
Developed new Excel spreadsheets for data submissions, increasing efficiency.
Performed utilization reviews for providers in the DIDD waiver program, ensuring compliance.
Managed third-party payer contracts, keeping files current and organized.
Experience
0-2 Years
Level
Entry Level
Education
B.S. in HA
Managed Care Coordinator Resume
Objective : Accomplished Managed Care Coordinator with 5 years of experience in optimizing healthcare delivery and ensuring compliance with payer regulations. Skilled in analyzing reimbursement structures and enhancing operational workflows. Committed to improving patient outcomes through effective collaboration with healthcare teams and leveraging data analytics for informed decision-making.
Created and submitted appeals to payers, achieving a 40% success rate.
Developed comprehensive spreadsheets for bulk appeals analysis, improving workflow efficiency.
Reviewed EOBs to ensure accurate payments and maintained optimal accounts receivable aging.
Conducted detailed audits of patient accounts for accuracy in charges and payments.
Monitored payer payments to ensure compliance with established fee schedules.
Secured insurance authorizations for procedures and tests as ordered by physicians.
Monitored patient progress and adjusted care plans as necessary.
Experience
2-5 Years
Level
Junior
Education
B.S.H.A.
Managed Care Specialist Resume
Headline : Results-oriented Managed Care Specialist with 7 years of expertise in healthcare reimbursement and payer relations. Proven ability to analyze and optimize managed care contracts, ensuring compliance and enhancing patient access to services. Strong collaborator with a track record of improving operational efficiencies and patient outcomes through data-driven strategies.
Skills : Analytical Skills, Decision Analysis, Performance Monitoring, Advanced Problem Solving, Health Informatics
Description :
Managed payer relations and negotiated contracts to optimize reimbursement for services rendered.
Conducted thorough analyses of reimbursement models, identifying opportunities for enhancing operational efficiencies.
Collaborated with multidisciplinary teams to ensure compliance with healthcare regulations and improve patient care delivery.
Tracked and appealed denied claims, ensuring accurate reimbursement aligned with contract agreements.
Provided detailed reports on claims status and reimbursement metrics to senior management.
Developed and administered managed care contracts, working closely with clinical staff to process referrals efficiently.
Trained staff on managed care policies and best practices, fostering a culture of compliance and excellence.
Experience
5-7 Years
Level
Senior
Education
B.S.H.A.
Senior Managed Care Specialist Resume
Summary : Dynamic Senior Managed Care Specialist with over 10 years of experience in optimizing managed care operations and enhancing payer relations. Expertise in developing strategic initiatives that drive compliance, improve reimbursement processes, and elevate patient outcomes. Proven ability to lead cross-functional teams and utilize data analytics to inform decision-making and foster innovative healthcare solutions.
Skills : Clinical Documentation, Health Data Management, Insurance Verification, Benefit Coordination, Chronic Care Management
Description :
Designed and executed educational programs for Northeast Ohio sales teams, resulting in record-breaking sales performance.
Partnered with health plans to implement effective smoking cessation initiatives, improving community health outcomes.
Conducted inquiries and analyses of industry best practices among Managed Care Representatives to enhance service delivery.
Organized and led the GSK National Managed Care Representative meeting, fostering collaboration among multiple managed care entities.
Reviewed remittances to identify and rectify denied claims, applying proficiency in ICD-9 and CPT coding for corrections.
Generated collections letters and managed follow-ups on outstanding account balances, improving cash flow.
Monitored managed care contracts' performance to ensure accurate claims processing, identifying trends in underpayments and overpayments.
Experience
7-10 Years
Level
Management
Education
BSHA
Managed Care Specialist Resume
Summary : Seasoned Managed Care Specialist with a decade of experience in enhancing healthcare delivery through effective contract management and payer relations. Expertise in analyzing reimbursement frameworks, ensuring compliance, and driving operational efficiencies. Passionate about utilizing data analytics to improve patient outcomes and foster collaborative relationships within healthcare teams.
Skills : Comprehensive Medical Billing Expertise, Expertise In Medical Collections, Interpersonal Skills, Risk Management, Quality Assurance
Description :
Evaluated new healthcare programs for potential integration.
Reviewed invoices and executed necessary financial transfers to maintain accuracy.
Ensured compliance with consumer credit regulations for self-pay accounts.
Contacted payers to follow up on unpaid claims, enhancing cash flow.
Maintained expertise in third-party payer regulations for Managed Care, Medicare, and Medicaid accounts.
Provided support during regulatory audits and compliance reviews.
Served as a liaison to resolve managed care issues, assisting with provider communications and claims research.
Experience
10+ Years
Level
Executive
Education
BSHA
Managed Care Consultant Resume
Objective : Results-driven Managed Care Consultant with 5 years of experience in optimizing healthcare operations and enhancing payer relationships. Expert in analyzing reimbursement structures and developing strategies that improve compliance and patient outcomes. Passionate about using data analytics to drive informed decisions and foster collaboration among healthcare teams.
Skills : Data Analysis Software, Communication Skills, Reimbursement Management, Data Management
Description :
Coordinated with insurance providers, medical offices, and patients to facilitate referrals efficiently.
Maintained accurate electronic and hard-copy records of referral activities for compliance and tracking.
Conducted in-depth research on patient insurance eligibility and benefits to optimize care delivery.
Resolved TennCare eligibility appeals, enhancing patient access to necessary services.
Developed educational materials on contract implications, improving staff understanding of managed care.
Communicated regulatory and reimbursement changes to senior management, ensuring organizational readiness.
Executed processes related to strategic pricing and contract performance to maximize yield.
Experience
2-5 Years
Level
Freelancer
Education
B.S. HCA
Managed Care Specialist Resume
Objective : Resourceful Managed Care Specialist with 2 years of experience in payer relations and compliance management. Skilled in evaluating reimbursement models and streamlining operational processes to enhance service delivery. Experienced in working collaboratively with healthcare teams to drive patient satisfaction and ensure adherence to regulatory requirements. Eager to utilize analytical skills to support healthcare initiatives.
Skills : Health Plan Coordination, Data Analysis Tools, Provider Relations, Cost Containment, Patient Education
Description :
Analyzed and processed applications for Long Term Care assistance, ensuring compliance with federal and state regulations.
Facilitated the expedited processing of urgent applications, significantly reducing wait times.
Reviewed and evaluated payer contracts, ensuring competitive offerings and compliance.
Monitored billing practices and regulatory changes to maintain compliance in managed care operations.
Collaborated with multidisciplinary teams to enhance service delivery and operational efficiencies.
Conducted thorough assessments of contract language for financial and operational impact.
Provided training and support to staff regarding managed care policies and procedures.
Experience
0-2 Years
Level
Entry Level
Education
B.S. in HA
Lead Managed Care Specialist
Resume
Headline : Strategic Lead Managed Care Specialist with 7 years of experience in enhancing payer relations and optimizing healthcare delivery. Demonstrated expertise in contract negotiation, compliance management, and data analysis to improve operational efficiencies and patient outcomes. Passionate about driving initiatives that align with regulatory standards and promote quality care.
Analyzed and optimized managed care contracts to enhance provider and patient satisfaction.
Collaborated with interdisciplinary teams to ensure adherence to healthcare regulations and standards.
Utilized data analytics to identify trends and improve operational efficiencies.
Conducted training sessions for staff on compliance and reimbursement protocols.
Managed relationships with payers to negotiate favorable contract terms.
Oversaw preauthorization processes to ensure timely patient care.
Implemented quality improvement initiatives to enhance service delivery.
Experience
5-7 Years
Level
Senior
Education
BSHM
Managed Care Specialist Resume
Summary : Accomplished Managed Care Specialist with a decade of experience in enhancing healthcare delivery and optimizing payer relations. Expert in analyzing reimbursement models, ensuring regulatory compliance, and driving operational efficiencies. Skilled at collaborating with cross-functional teams to improve patient outcomes through data-driven strategies and innovative solutions.
Skills : Healthcare Regulations, Network Management, Service Delivery, Stakeholder Engagement, Training And Development
Description :
Conducted thorough analyses of managed care contracts to optimize reimbursement strategies.
Collaborated with benefits departments to enhance annual enrollment activities.
Maintained compliance with healthcare regulations and industry best practices.
Monitored utilization management processes for efficiency.
Coordinated interdepartmental initiatives to improve patient care services.
Managed credentialing verification processes for licensed personnel in home health care.
Prepared and presented monthly performance metrics to stakeholders.
Experience
7-10 Years
Level
Management
Education
B.S. in HCM
Managed Care Specialist Resume
Summary : Strategic Managed Care Specialist with over 10 years of experience in optimizing reimbursement processes and enhancing payer relationships. Proven expertise in analyzing complex data to drive compliance and operational efficiency. Committed to fostering collaborative healthcare environments that prioritize patient outcomes and effective service delivery.
Skills : Problem Solving, Time Management, Attention To Detail, Customer Service, Compliance Monitoring
Description :
Conducted comprehensive audits of hospital accounts to ensure accurate billing and compliance with payer contracts.
Analyzed reimbursement patterns to identify trends and optimize revenue cycle processes.
Collaborated with cross-functional teams to update patient demographic information and streamline account management.
Maintained compliance with company policies and regulatory standards through diligent oversight.
Maximized recovery of delinquent accounts by implementing targeted collection strategies.
Documented all collection activities and maintained organized records for accountability.
Fostered collaborative relationships with internal teams to enhance service delivery and patient satisfaction.
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