Managed Care Specialist

Job Description

Job Description

Community Services Department

EXTENDED LAST DAY FOR FILING: August 21, 2026

EOE

DISTINGUISHING FEATURES OF THE CLASS :  The work involves managing and coordinating the delivery of behavioral health services and enrollment into managed care programs. The incumbent ensures compliance with organizational policies and payer requirements. This includes collecting, preparing and analyzing data; providing billing services, correcting errors, tracking payments, investigating and resolving appeal denied or rejected claims; monitoring the effectiveness of services; identifying opportunities for improving performance and reporting progress on performance measures. The work is performed under the direct supervision of the Behavioral Health Billing & Claims Management supervisor and general supervision by the Business Office Manager. May oversee the work of others performing related activities. Performs related duties as required.

TYPICAL WORK ACTIVITIES :  (Illustrative only)

• Identify and ensure that all available health insurance resources are utilized to offset medical expenses incurred by clients of the agency.
• Compile and review documents required for managed care, insurance, Medicaid, Medicare and other payer contracts.
• Assist in internal and external insurance and billing audits by gathering requested documentation, ensuring compliance with organizational policies and payer requirements, responding to audit inquiries, and assisting with the implementation of corrective actions as needed.
• Record and maintain accurate contract information and payer communications, appeals, authorizations, and claim activity within the electronic health record and billing systems.
• Submit, monitor for compliance, and reconcile electronic claims to managed care organizations and third-party payers.
• Provide support to billing services, correct errors and track payments;
• Assist in investigating, resolving, and appealing denied or rejected claims by identifying root causes and coordinating corrective actions with clinical and billing staff.
• Communicate with insurance representatives when required regarding claim status, payment discrepancies, prior authorizations, and reimbursement issues.
• Review explanation of benefits (EOBs) remittance advices, and payment reports to identify billing discrepancies and initiate corrections.
• Collaborate with clinical, registration, and billing staff to resolve documentation deficiencies that impact claim submission and payment.
• Assist in generating and analyzing reports related to denials, authorizations, aging accounts receivable, payer trends, and reimbursement performance.
• Compile and review data to measure performance, clinical outcomes and identify problems, gaps.
• Assist in developing and implementing billing workflow improvements that enhance efficiency, compliance, and revenue cycle performance.
• Perform other related duties as required.

FULL PERFORMANCE KNOWLEDGE, SKILLS, AND ABILITIES: Good knowledge of Medicaid/ Medicare/Managed Care and insurance policies and procedures reimbursement for behavioral health services; good knowledge of HIPPA and Corporate Compliance regulations; working knowledge of NYS OMH and OASAS regulation; working knowledge of medical terminology, insurance policies and managed care concepts; strong analytical and problem solving abilities; ability to perform electronic billing accurately; ability to collect, organize and review data; ability to communicate effectively both verbally and in writing; ability to write clear and accurate reports and maintain records as required; ability to enter, retrieve and interpret information in central computerized systems; ability to establish and maintain effective relationships with clients, staff and providers; ability to work independently; ability to manage multiple priorities and meet deadlines; ability to exercise initiative and tact.

MINIMUM QUALIFICATIONS :  Graduation from high school or possession of a high school equivalency diploma; AND

• Graduation from a regionally accredited or New York State registered college with an Associate's Degree or higher and one (1) year of full-time or its part-time equivalent experience in managed care, insurance or healthcare business operations; or
• Three (3) years of experience as defined in (a) above.

NOTE : Successful completion of coursework in business administration, healthcare administration or closely related field at a regionally accredited college or university, or one accredited by the New York State Board of Regents to grant degrees, may be substituted for up to one-half (1/2) of the required experience with three (3) semester credit hours of related coursework as indicated above being equivalent to three (3) months of experience.

CLASSIFICATION:  Competitive