Specialist Managed Care- Mental Health

Ridgeview Medical Center
United States, Minnesota, Waconia
Feb 14, 2025
Purpose of Job The Managed Care Specialist (MCS) will be responsible for managing requests for incoming and outgoing referrals and prior authorizations. Acts as a liaison between health plans, patients and providers. Job Functions Completes the insurance and benefits verification to determine the patient's benefit level for services and documents information in the EHR. Responsible for self-education to keep up with changes happening with the insurance payers regarding prior authorization. Screens payer medical policies to determine if the scheduled procedure requires a referral or prior authorization. Initiates treatment authorization requests and pursues referrals per payer guidelines. Works with clinical staff to determine likely ICD-0 and/or CPT codes. Ensures that pre-certification and admission notification requirements are met per payer guidelines. Requests and/or obtains medical records needed for prior authorization/referral purposes. Process authorization denial appeals when necessary and communicates with department timely when denials are received prior to service in order for department to make decision as to whether or not service will be provided. Works with Patient Financial Service to follow up with insurance payers on prior authorization denials. Serves as a liaison between patient, insurance company and provider. Provides professional and courteous customer service to internal and external customers. Performs other duties as assigned. Minimum Education/Work Experience High school diploma or equivalent 2 years working in revenue cycle, insurance verification/eligibility, financial securing/prior authorization, or related field Strong customer service experience Knowledge/Skills/Abilities Ability to meet and maintain the necessary background checks as aligned with position functions Ability to communicate in the English language for effective written and verbal correspondence in order to complete job functions as mentioned above Ability to effectively handle high-stress, face paced environment Ability to multi-task Ability to perform basic math functions and count money Ability to serve patients in a friendly and efficient manner Knowledge of basic computer functions and Microsoft Office applications Ability to respond appropriately to unpredictable situations and diverse patient populations Ability to work autonomously and as a team Capable of making independent decisions with the use of good critical thinking and problem solving skills Displays a higher level of problem solving and conflict management skills Attention to detail Working knowledge of insurance related to healthcare and a demonstrated ability to use that knowledge for problem solving Preferred Qualifications Post-secondary education in a related field Familiar with medical terminology Physical Demands Link to Employee Health Physical Demands Compensation Many factors are taken into consideration when determining compensation such as: the requirements of the position, experience, education, knowledge, and skills along with location and internal equity. Pay listed does not include any shift, weekend, or other differentials. Benefits Ridgeview strives to provide comprehensive and market competitive benefits to meet the needs of our employees and their families. Click here to view the benefits available.