Managed Care Specialist
Gahanna, OH
Job Description

Corporate Managed Care Specialist

Due to recent growth CommuniCare is now hiring for a key position, Corporate Managed Care Specialist. The Corporate Managed Care Specialist reports to the Vice President of Managed Care and is responsible for providing education and training on managed care to ensure appropriate clinical services are provided and optimal reimbursement is received. This includes developing training material, policy and procedures and working with health plans on specialized programs at the direction of the Vice President of Managed Care. This role serves as a key member of the Managed Care Team in helping develop quality Managed Care programs in conjunction with the Directors of Managed Care. Position supports Divisions with the maintenance and development of the Managed Care Team Link site, Audits of managed care systems to ensure maximization of reimbursement for the care being provided as well as ease of use by field personnel. Developing materials to partner with Managed Care Plans.

Job duties & responsibilities

  • Works with Vice President of Managed Care to develop and train on Managed Care policies and procedures that lead to positive growth in managed care and appropriate reimbursement for the care provided.
  • Review managed care policies, procedures and systems to maximize workflow. Makes recommendations to Vice President of Managed Care.
  • Provides education to other health care providers, the facility's care team on Managed Care.
  • Audit managed care process to ensure we are maximizing reimbursement for pharmacy and level based contracts
  • Explore continued accreditation that sets Communicare at the forefront of the industry for managed care and case management. ( HEDIS and NQCA requirements)
  • Works directly with Directors of Managed Care to ensure all new Case Managers are oriented to Communicare' s Managed Care policies and systems.
  • Coordinates the Managed Care training for new employees with the Director of Managed Care to ensure all new Admission teams, BOM's, Therapy Directors and Administrators are trained within first 90 days on Managed Care products, Reimbursement and collaboration with local payers.
  • Works on Problem resolution such as ADR process, PCC, and other managed care work flow.
  • Maintains the Managed Care Website and access for all Communicare Employees as well as the loading and maintenance of the Managed Care Tracking reports.
  • Manages Managed Care Portal Access.
  • Conducts job responsibilities in accordance with the standards set in the Code of Conduct, policies and procedures, applicable federal and state laws, and applicable professional standards

At CommuniCare, you will enjoy an excellent salary and an outstanding benefits package in a pleasant, team environment. Qualified candidates, please submit your resume and letter of interest for confidential consideration.

  • Graduate of an accredited School of Nursing
  • Valid RN or LPN license in the state of Ohio - RN Preferred
  • Five years of experience in a long term care environment preferred, working directly with Managed Care Services
  • Experience with the case management process
Job Type Full-time