Managed Care Specialist BCSU

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, Inter Qual 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/ICD
10, and medications. Maintain good standing relationships with team and insurance companies.

• 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.

• 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 system
• Serves as back up for CSU billing when Manager is out of the office
• Ability to arrive/report to work on time and ready to work.
• Ability to abide by company attendance policy.
• Ability to abide by principles of EEO compliance and a workplace of dignity and respect.
• Ability to work cooperatively in a group/team setting.
• Ability to show respect to others.
• Ability to take guidance and direction from supervisors.
• Ability to report to work with clean hygiene.
• Ability to adhere to company /program dress code standards.
• Ability to professionally communicate with others.
• Ability to record minutes from meetings.
• Ability to keep information confidential.
• Ability to clearly discuss and train staff to discuss clinical/financial information with third party payers, co-workers and clients.
• Ability to encourage treatment team to fully assess for presenting needs and assist in how to address needs.
• Ability to listen to and understand information and ideas presented verbally and in writing.

• The ideal but not required candidate for this position is an LPN, Utilization Review Specialist, or Managed Care Specialist.
• Must have billing, denials, and appeals experience.
• Must…