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Become A Managed Care Coordinator

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Working As A Managed Care Coordinator

  • Communicating with Supervisors, Peers, or Subordinates
  • Making Decisions and Solving Problems
  • Establishing and Maintaining Interpersonal Relationships
  • Evaluating Information to Determine Compliance with Standards
  • Developing and Building Teams
  • Deal with People

  • Unpleasant/Angry People

  • Mostly Sitting

  • Make Decisions

  • $94,500

    Average Salary

What Does A Managed Care Coordinator Do At Beth Israel Deaconess Medical Center

* Collaborates with referring physicians, patients and support staff to request, obtain, record, and attach primary and/or specialty care managed care referral and authorization requests for multiple managed care insurance payers for a high volume of patients.
* Utilizes electronic technologies to initiate, request, and procure a high volume of referral and authorizations for multiple managed care payers.
* Educates patients about the referral process, programs offered, and services provided at BIDMC and affiliated CareGroup institutions.
* Communicates to the provider and/or patient the level of care, number of visits being authorized.
* Communicates with managed care payers to resolve patient referral management issues.
* As appropriate, coordinates referrals with hospital's discharge planner and registration and pre-certification admitting department as required by the insurance company.
* Provides referral management training and oversight to department new hires.
* Contributes as a managed care resource for everyone on the unit including all patients, physicians, social workers, nurses, practice assistants, and support staff

What Does A Managed Care Coordinator Do At Community Regional Medical Center

* Provides direction and supervision to assigned department staff in areas of contracting, contract management and provider relations.
* Contracting:
* Responsible for evaluating and negotiating contracts with health plans on behalf of the Community Foundation Medical Group (CFMG) and practice management clients.
* Provides contracting support for Community Care Health Plan (CCHP).
* Coordinates the transitioning/onboarding of new providers into CFMG by working closely with health plan payors and the operations team.
* Responsible for network development and network management functions for SCP, CFMG, ACO, and practice management clients as assigned.
* Contract Management:
* Accountable for the accurate maintenance and management of provider databases (including the MSO and SHS Roster Program) for regular and specialty contracting such as CFMG and ACOs.
* Responsible for required updates and plan reporting.
* Acts as a liaison with Patient Financial Services, physician offices and health plans to resolve contractual issues and ensure compliance with negotiated contractual terms.
* Communicates with operations regarding contract modifications impacting operations.
* Performs in-services for new and modified contracts.
* Provider Relations:
* Responsible for building and maintaining productive and positive relationships with physicians, office staff, facilities, brokers and health plans.
* Works with internal and external customers to ensure contract compliance and to strengthen business relationships.
* Staff Management:
* Assigns, directs and reviews the work of subordinates, manages staffing and scheduling functions to achieve department objectives.
* Administers the HR processes for assigned staff: participates in the hiring and interviewing process; completes time and attendance; coordinates the performance evaluation process to ensure consistent evaluations within scheduled time frames; performs disciplinary processes in service area and advises the Director of all final written warnings and terminations.
* Performs other duties as assigned

What Does A Managed Care Coordinator Do At Amerihealth Caritas

* This position is responsible for ensuring that all problems, complaints, grievances and appeals, presented by Plan members or their representative, are resolved in accordance with established policy and procedures, National Committee for Quality Assurance, and Federal/State guidelines.
* The Grievance and Appeals Coordinator acts as a member advocate and independently communicates with Advocacy Groups, Community Representatives, Providers, Physicians, and all Plan departments including, but not limited to, Legal and Government Affairs, to interpret and enhance the understanding of policies and procedures for complaints, grievances and appeals.
* Assist member or provider, or provider on behalf of the member, in filing a formal appeal and grievance.
* Coordinates and handles all member and provider appeals and grievances, including the member grievances, appeals, requests and disputes.
* Identifies and investigates the reason for denial trends and report findings to the appropriate entities.
* Identifies deficiencies and develop corrective action plan to ensure compliance is met.
* Update and generate authorizations for services that have been appealed, as well as communicate this information to various departments
* Prepares, develops and presents written case summaries for all adverse determination for the purpose of conducting State Fair Hearings
* Actively seeks the involvement of the legal department or government affairs, whenever necessary, for clarification and supporting documentation.
* Documents, in the appropriate computer system, all correspondence with a member and or a provider related to an appeal or grievance issue.
* Uses sound judgment and discretion when communicating findings related to an appeal.
* When necessary, will obtain authorization for release of sensitive and confidential information.
* Tracks and reports case turnaround time and follows up with the plan, when this requirement is not met.
* Responsible for communicating NCQA requirements to appropriate personnel involved in the member appeal process.
* Keeps current with rules, regulations, policies and procedures relating to Plan member benefits, member’s rights and responsibilities, and Complaints and Grievances.
* Maintains the performance standard of processing 95% of all member first level appeals within 30 days and grievance within 90 days of receipt, as defined in all regulatory and accreditation standards.
* Follows up when compliance standards are not meet.
* Adheres to Plan policies and procedures and supports the mission and values of Plan

What Does A Managed Care Coordinator Do At Cherokee Nation

No supervisory responsibilities are required

What Does A Managed Care Coordinator Do At Beth Israel Deaconess Medical Center

* Work collaboratively with APG PCPs, patients and practice support staff to coordinate, and process all specialty care managed care referral authorization requests in compliance with APG's, BIDMC's and BIDPO's contractual rules and agreements for multiple managed care insurance payers.
* Utilize electronic technologies to initiate, issue, and administratively sign off on a high volume of referrals.
* Learn and remain proficient on multiple electronic technologies used by the APG practices and BIDMC to initiate referral requests in an efficient and timely manner.
* Technologies will include but are not limited to (POS) Point of Service Device, Health Wire Network, Aetna WebMD, NEHEN, HPHC Connect, and other computer and web-based technology, Navinet and NIA.
* Serve as a daily point of contact and as an organizational resource for APG patients, families, specialty practices, physicians and support staff on APG managed care related issues.
* Communicate to the specialist and/or patient the level of care, number of visits being authorized (e.g. one consult only vs. a consult and treatment), and the extent of the diagnostic testing being authorized.
* Communicate with managed care payers to resolve patient referral management issues; coordinate with Patient Accounts, and other internal and external customers to resolve patient billing problems.
* Help provide referral management training to new hires.
* Work with extremely sensitive and highly confidential patient information and adhere to policy of maintaining patient confidentiality.
* Maintain current knowledge base of referral and authorization plan rules and policies for multiple managed care payers and multiple specialties and ancillary/diagnostic testing as they apply to issuing PCP approvals.
* Work closely with patients and PCP's to refer patients with complex referral needs and complicated problems or situations to the case management at the insurance companies

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How To Become A Managed Care Coordinator

Most medical and health services managers have at least a bachelor’s degree before entering the field. However, master’s degrees are common and sometimes preferred by employers. Educational requirements vary by facility.

Education

Medical and health services managers typically need at least a bachelor’s degree to enter the occupation. However, master’s degrees are common and sometimes preferred by employers. Graduate programs often last between 2 and 3 years and may include up to 1 year of supervised administrative experience in a hospital or healthcare consulting setting.

Prospective medical and health services managers typically have a degree in health administration, health management, nursing, public health administration, or business administration. Degrees that focus on both management and healthcare combine business-related courses with courses in medical terminology, hospital organization, and health information systems. For example, a degree in health administration or health information management often includes courses in health services management, accounting and budgeting, human resources administration, strategic planning, law and ethics, health economics, and health information systems.

Work Experience in a Related Occupation

Many employers require prospective medical and health services managers to have some work experience in either an administrative or a clinical role in a hospital or other healthcare facility. For example, nursing home administrators usually have years of experience working as a registered nurse.

Others may begin their careers as medical records and health information technicians, administrative assistants, or financial clerks within a healthcare office.

Important Qualities

Analytical skills. Medical and health services managers must understand and follow current regulations and adapt to new laws.

Communication skills. These managers must effectively communicate policies and procedures with other health professionals and ensure their staff’s compliance with new laws and regulations.

Detail oriented. Medical and health services managers must pay attention to detail. They might be required to organize and maintain scheduling and billing information for very large facilities, such as hospitals.

Interpersonal skills. Medical and health services managers discuss staffing problems and patient information with other professionals, such as physicians and health insurance representatives.

Leadership skills. These managers are often responsible for finding creative solutions to staffing or other administrative problems. They must hire, train, motivate, and lead staff.

Technical skills. Medical and health services managers must stay up to date with advances in healthcare technology and data analytics. For example, they may need to use coding and classification software and electronic health record (EHR) systems as their facility adopts these technologies.

Licenses, Certifications, and Registrations

All states require licensure for nursing home administrators; requirements vary by state. In most states, these administrators must have a bachelor’s degree, complete a state-approved training program, and pass a national licensing exam. Some states also require applicants to pass a state-specific exam; others may require applicants to have previous work experience in a healthcare facility. Some states also require licensure for administrators in assisted-living facilities. For information on specific state-by-state licensure requirements, visit the National Association of Long Term Care Administrator Boards.

A license is typically not required in other areas of medical and health services management. However, some positions may require applicants to have a registered nurse or social worker license.

Although certification is not required, some managers choose to become certified. Certification is available in many areas of practice. For example, the Professional Association of Health Care Office Management offers certification in medical management, the American Health Information Management Association offers health information management certification, and the American College of Health Care Administrators offers the Certified Nursing Home Administrator and Certified Assisted Living Administrator distinctions.

Advancement

Medical and health services managers advance by moving into higher paying positions with more responsibility. Some health information managers, for example, can advance to become responsible for the entire hospital’s information systems. Other managers may advance to top executive positions within the organization.

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Managed Care Coordinator jobs

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Top Skills for A Managed Care Coordinator

InsuranceCompaniesMedicaidMedicareAdvantageFinancialCareCoordinatorHealthPlanHealthCareProvidersCustomerServiceUtilizationManagementFunctionsDataEntryHMOPrimaryCareCareContractsClinicalStaffMedicalRecordsMedicalNecessityClinicalReviewDurableMedicalEquipmentUtilizationReviewNon-ClinicalData

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Top Managed Care Coordinator Skills

  1. Insurance Companies
  2. Medicaid
  3. Medicare Advantage
You can check out examples of real life uses of top skills on resumes here:
  • Maintain files and daily correspondence calls with insurance companies to ensure proper payments were fully collected.
  • Assessed services for Medicare, Medicaid and Private Insurance to provide community and social services coordination.
  • Coordinated Marketing strategies with contracted Medicare Advantage health insurance plans Handled and trusted with patient/ provider personal confidential information.
  • Maintain charge master list and oversee preparation of financial research reports for administration.
  • Served as District managed care coordinator.

Top Managed Care Coordinator Employers

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