Job Description
The Operations Specialist Managed Care reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
Responsibilities:
- Works with multiple operations departments including Revenue Cycle, Information Systems, Case Management, Access, Physician Practices and Hospital/Ancillary Clinical Areas to implement the operations of the managed care, government and special project contracts, as well as any major administrative payer requirements that have a material financial impact.
- Works with Sr. Operations Specialists/Analysts to review on a monthly basis all newsletter, payor updates and then communicate through the Insurance on Demand tool. (i.e. Contract Announcement, Contract Termination and Payor Newsletter/Updates, etc.).
- Works with Sr. Operations Specialist to support resolving encounters related to prior authorization, concurrent review, discharge placement and peer to peer issues resulting in nonpayment or denials of payment.
- Responsible for supporting various departments through the escalation of tickets through the Service Now portal based on the appropriately assigned payor and/or category.
- Responsible for creating and maintaining the physician billing reimbursement tools based on contract and payor terms and reviewed for any updates that are needed regularly.
- Participates in regular meetings with the vendor in maintaining and updating the insurance on demand tool. Continuously provides feedback and recommendations for a better end user experience that provides an efficiency and ease of navigating the tool.
- Provides Insurance on Demand trainings to departments and individuals as needed, supports the Insurance on Demand training module in the Academy Learning Module.
- Updates to the prior authorization module with prior authorization and/or pre-determination documents as payors publish changes and as needed.
- Supports special programs or service lines to address payor network status and policy information.
- Performs special projects as duties as assigned by the Manager and Director of Managed Care.
