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Managed Care Coordinator

Location: MAITLAND, FL, United States
Zip Code: 32751
Job ID: 385

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Description

 

Job Summary:

The Managed Care Coordinator is responsible for overseeing the provider credentialing and enrollment process, ensuring compliance with managed care organizations (MCOs), and assisting with the resolution of claim and authorization issues. This role involves communication and collaboration with internal teams and external stakeholders to ensure timely and accurate provider enrollment, maintaining up-to-date records, and by supporting the negotiation of reimbursement rates. The position also requires proactive management of re-credentialing of providers and centers to ensure continuous participation in health plans. The ideal candidate will have a strong understanding of healthcare insurance processes and be detail-oriented in maintaining accurate provider files and facilitating effective relationships with payors.


Key Responsibilities:

  1. Provider Enrollment & Credentialing:
    • Manage the submission and processing of initial and re-credentialing applications for providers, ensuring compliance with all necessary documentation requirements for health plans.
    • Maintain up-to-date and accurate provider records, tracking and verifying credentialing status to ensure timely renewals and re-credentialing.
  2. Collaboration with Managed Care Organizations:
    • Act as the main point of contact between the organization and managed care representatives to facilitate the enrollment and credentialing of providers.
    • Address inquiries and resolve any issues related to provider status, claims, or network participation with health plans.
  3. Claims Denials & Authorization Issues:
    • Collaborate with Revenue Cycle Management and clinical teams to resolve claims and authorization denials related to credentialing and enrollment issues.
    • Investigate denial trends and work on corrective actions to prevent future issues with claims.
  4. Rate Schedule Management:
    • Assist with managing and updating rate schedules for providers, ensuring that all reimbursement terms are accurately reflected in internal systems.
    • Support the negotiation of better reimbursement rates with health plans, working closely with the Managed Care teams.
  5. Compliance with Payor Requirements:
    • Ensure that all provider enrollment and credentialing documents are submitted in compliance with the specific requirements of each health plan or payer.
    • Stay informed on changes to payer policies and requirements, ensuring that all provider files are up-to-date and compliant.
  6. Process Improvement & Documentation Accuracy:
    • Review and provide feedback on internal credentialing and enrollment processes to improve efficiency and accuracy.
    • Suggest improvements in workflows that streamline enrollment tasks and improve provider onboarding and re-credentialing processes.
  7. Internal and External Communication:
    • Maintain regular communication with internal teams (clinical, finance, legal) and external stakeholders (payors, health plans) to ensure provider enrollment is handled efficiently and in a timely manner.
    • Provide updates on the status of provider enrollments, credentialing, and rate negotiations to key internal stakeholders.
  8. Confidentiality & Discretion:
    • Handle sensitive provider and payer data with discretion, maintaining confidentiality in line with HIPAA and organizational policies.
    • Exercise sound judgment when sharing confidential information with internal teams and external partners.
  9. Attendance & Participation in Meetings:
    • Attend regular department meetings, team discussions, and company-wide meetings as required.
    • Contribute insights and updates during meetings, offering feedback to improve processes and procedures.
  10. Other Duties as Assigned:
    • Perform additional tasks as assigned by leadership to support the department’s goals and ensure smooth operational workflows.

Qualifications:

Education & Experience:

  • Bachelor’s degree in Business Administration, Healthcare Management, or related field.
  • 3-5 years of experience in provider credentialing, healthcare enrollment, or managed care.
  • Familiarity with healthcare insurance systems, credentialing processes, and payor enrollment systems.
  • Experience with credentialing and contract management software, such as CredentialStream or similar tools, is preferred.
  • Prior experience working with behavioral healthcare organizations is a plus.

Skills & Knowledge:

  • Knowledge of healthcare terminology, ICD-10, CPT coding, and modifiers.
  • Strong organizational skills and attention to detail.
  • Ability to work independently and as part of a team.
  • Excellent written and verbal communication skills.
  • Ability to resolve complex issues with a proactive, solutions-oriented approach.
  • Knowledge of PECOS, NPPES, CAQH, SAMSHA and payer portals

Work Environment:

  • Hybrid: This role requires in-office attendance three days a week for collaboration and administrative tasks.

 

Supervisory Responsibilities: 

(Scope of the person’s authority, including a list of jobs that report to this job).

  • None

 

Essential Qualifications:

(To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the competencies (minimum knowledge, skill, and ability) required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions). 

 

Education/Licensure/Certification:    

This position requires a Bachelor's degree in business or related field.

 

Required Knowledge:                        

The candidate has knowledge of the credentialing and contracting process with third party healthcare insurance plans. Knowledge of major U.S. health plans, NPI Registry, taxonomies, EIN/Tax ID and governmental payer entities. Must be familiar with computers, medical terminology, ICD-10 and CPT coding, and modifiers.

                                                

                                    

Experience Required:                         

This position requires a minimum of 3-5 years experience in either the payer or provider environment. Demonstrated ability in resolving complex issues is required. Experience with behavioral healthcare organizations are a plus.

 

 

Skill and Ability:                                

 The candidate has the ability to work collaboratively with colleagues. Represent the company in a professional manner. Strong organizational skills with a keen ability to prioritize and multitask. Ability to adhere to and meet deadlines. Good communicator (oral and written). Strong administrative and data management skills. Ability to raise issues proactively and in a timely manner. Strong presentation skills Ability to work with software systems.

 

Physical Demands/Work Environment:

(The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.)

 

Core Competencies:

 

  • Analytical Skills
  • Excellent verbal and written communication skills
  • Proficient with office productivity software (e.g. Microsoft Office Suite, Google documents, etc).
  • Detail Orientation/Attention to Detail
  • Ability to adapt to changing priorities
  • Ethics/Values/Integrity
  • Information Gathering
  • Problem Solving
  • Time Management

 

Mental Activities:

(The mental activities described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.)

 

Reasoning Ability:                             

 Ability to resolve practical problems and deal with a variety of  concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram or  schedule form. Ability to maintain patient and treatment confidentiality.

 

Mathematics Ability:                          

Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, and volume.

 

Language Ability:                              

 Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, and governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from fellow employees and managers.

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