The Managed Care Specialist will complete all Managed Care/UR contract requirements pertaining to CSU inpatient length of stay approvals for clients in both CSU inpatient facilities. The MCS will monitor, coordinate, and provide necessary verbal and written documentation as required by the payor. The MCS must understand all aspects of the managed care system, including requirements and protocols, InterQual criteria, verification of behavioral health benefits, precertification, utilization review, peer review, discharge review, appeals, and claims process. Understand the assessments, treatment planning, continuing care recommendations, DSM/ICD10, and medications. Maintain good standing relationships with team and insurance companies.

General Expectations:

In the performance of their respective tasks and duties, all employees are expected to conform to the following:

Adhere to all PRC policies and Code of Conduct standards and at all times exhibit all

PRC's Core Values.

Perform quality work within deadlines with or without direct supervision.

Interact professionally with other employees, customers and vendors.

Work independently, while understanding the necessity for communicating and coordinating work efforts with other employees and organizations, as required.

Comply with all Center policies and procedures except those for which the employee gives notice of the need for reasonable accommodation and for which the Center can make such reasonable accommodations.

An employee in this position must be able to react to change productively.

Attends all scheduled work hours, meeting, training, and other center functions.

Troubleshoot authorization discrepancies between PRC and the insurance companies.

Serve as liaison between providers of care and insurance companies.

Comply with no precept/LCD process.

Provide training to staff relevant to managed care/insurance/authorizations, upon request.

Responsible for CSU authorization process including:

Attend daily CSU staff meetings for update/status of all client admissions/discharges.

Insurance Verification and data entry of all admits to the CSU.

Identify all insured clients with proper and timely authorization for CSU services.

Complete utilization reviews, discharge reviews, schedule peer reviews according to payor requirements. Enter accurate data entry as required.

Submit clinical records for appeals following no authorization and denial of authorization.

Initiate, follow up on and determine final resolution for all appeals.

Hold payors accountable for their own UR policies and procedures.

Keep electronic records up to date with client authorization information, status and numbers for current and past clients.

Update CSU payor log and distribute as required.

Communicate concerns effective and immediately.

Provide verbal status on authorizations, missing documentation, and needed clinical information to obtain authorizations.

Follow up with emails to ensure request are complete, hold departments accountable for gathering needed information within expected timeframe.

Register and discharge detailed data for CFBHN clients in the IhSIS syste

Serves as back up for CSU billing when Manager is out of the office

Essential Duties/Requirements/Activities:

1. Ability to arrive/report to work on time and ready to work.
2. Ability to abide by company attendance policy.
3. Ability to abide by principles of EEO compliance and a workplace of dignity and respect.
4. Ability to work cooperatively in a group/team setting.
5. Ability to show respect to others.
6. Ability to take guidance and direction from supervisors.
7. Ability to report to work with clean hygiene.
8. Ability to adhere to company /program dress code standards.
9. Ability to professionally communicate with others.
10. Ability to record minutes from meetings.
11. Ability to keep information confidential.
12. Ability to clearly discuss and train staff to discuss clinical/financial information with third party payers, co-workers and clients.
13. Ability to encourage treatment team to fully assess for presenting needs and assist in how to address needs.
14. Ability to listen to and understand information and ideas presented verbally and in writing

Qualifications:

1. The ideal but not required candidate for this position is an LPN, Utilization Review Specialist, or Managed Care Specialist.
2. Must have billing, denials, and appeals experience.
3. Must have strong organization skills and be able to make decisions and work independently.
4. Knowledge to facility systems and organization as they pertain to medical records and organization review.
5. Excellent customer facing and phone skills.
6. Communication and interpersonal skills to develop relationships with clients, staff, providers, and payors.
7. Strong organization skills with a proven ability to multi-task and manage time.

Education:

High School diploma (GED), AA Degree a plus

Experience:

5+ years of customer services

5+ years in a business setting

3+ years clinical appeals

3+ years treatment/discharge planning

3+ years communicating with external organizations.

1+ years in collections in the Health Care Environment

Certifications:

None

Training:

20 hours professional enhancement training annually including all PRC required.

Credible/IhSIS/SharePoint training as needed to perform assigned job duties.

Knowledge and Skills:

1. Excellent written and verbal communication skills, including oral presentations.
2. Highly motivated, able to learn quickly and prioritize multiple tasks.
3. Proficient in Word, Excel and the ability/willingness to learn other applications.
4. Excellent organizational skills including: setting up/maintaining files.
5. Proactive approach to problem resolution.
6. Familiarity with medical terminology.
7. Working knowledge of the healthcare revenue cycle process.
8. Strong interpersonal, communication and persuasion/negotiation skills required to effectively interact with internal and external parties.
9. Must be able to follow detailed instructions.
10. Consistently exercises critical thinking skills or uses logic and reasoning to assess and resolve problems.
11. Quickly makes sense of, combines and organizes information.
12. Consistently maintain a professional and approachable demeanor.
13. Able to work under pressure and meet stringent deadlines in fast-paced environment.
14. Successfully alternates between two or more activities or sources of information.
15. Accepts responsibility and maintains a high level of accountability.
16. Handle unresolved inquires/issues

Safety Equipment

Universal Precautions

Comply with Occupational Safety and Health Administration (OSHA) rules and regulations

Life Safety Equipment (fire extinguisher)

Transportation:

Must have reliable transportation

Machines, Tool and Equipment Used

Computer, telephone- multi line, fax, copier, Calculator

Technology Requirement:

As an employee of Peace River Center, if you are not assigned a company-issued phone, you will be required to authorize the use of the Microsoft Authenticator app on your personal mobile device. This is necessary to access our payroll and communication system, Paycor, and Microsoft email as examples. This will ensure secure and efficient communication with the organization.

Supervisory Relationship(s)

None

Work Environment:

Exposure to advise working conditions due to people who are mentally ill, who may be psychotic, who may present some exposure to communicable diseases, be verbally abusive or present a threat of violence.

EEO Statement

One of the greatest assets of the PRC is the ethnic, cultural, and social diversity of its employees. PRC takes great pride in the diversity and values and respect of all its employees, regardless of race, color, sex, marital status religion, national origin, ancestry, genetic information, age, disability, gender identification, or sexual orientation.