Managed Care Specialist

Job Description

Primary Accountability

The Managed Care Specialist is responsible for contributing towards the efforts of the Managed Care department through support of managed care contracting requirements, the provider credentialing process, and maintaining IPA relationship(s).


Description of Primary Responsibilities

1. Responsible for primary IPA and Health Plan day to day interactions and activities, including, but not limited to:
   1. Addressing membership, credentialing, and referral related issues.
   2. Processing and reviewing monthly membership attributions.
   3. Analyzing and identifying membership trends for communication organization wide.
   4. Researching, compiling, and drafting responses to Health Plan patient grievances.
   5. Reviewing and submitting for approval, Health Plan requests for medical records.
   6. Coordinating external party requests for remote EMR access and/or medical record retrieval.
   7. Facilitating the scheduling of Health Plan contractual audit requests alongside FHCN staff and departments.
   8. Active participation in Health Plan based collaborative discussions, trainings, and Community Advisory Committee based meetings.
2. Responsible for producing and validating monthly reporting related to the ongoing activities of the Managed Care department, including but not limited to:
   1. Assigned membership trends and market shared analysis
   2. Quality Improvement health plan initiatives
   3. Specialist network adequacy and improvement opportunities
   4. Provider credentialing based activities
   5. Other reporting as determined by business needs
3. Assists the Credentialing Specialist(s) with the initial credentialing, reappointment, and hospital privileging process, as needed.
4. Facilitates the completion of Health Plan and State Sponsored Program enrollments through collection, assembly, and delivery of applications for final review and submission by the Managed Care Manager.
5. Responsible for adhering to the Attendance and Absenteeism Policy, recognizing that regular attendance is considered an essential function of all FHCN positions. Absenteeism is not being at work or failing to attend a paid workshop, training, or event unless the absence is protected by law.
6. Ability to present to and work at any FHCN location, both at the beginning of a shift or during a shift, based on business need.
7. Other duties as assigned.

Description of Primary Attributes

Professional & Technical Knowledge:

Effective June 1, 2026, all individuals hired into the role must:

1. Possesses work-related skills at a higher level than completion of high school, including formal written and verbal communications skills, computational and computer skills, mathematical, and technical skills.
   1. Preferred completion of an Associate's Degree program with a recognized major and a minimum cumulative GPA of 2.5
   2. Have proof of completion of high school with a minimum overall GPA of 2.5 or completion of General Educational Development (GED) with a minimum overall score of 162.5, and health care related knowledge frequently acquired through completion of a trade school, para-professional, or certificate type program.
   3. If an individual has completed a degree at a higher level than required by the role and had a stronger GPA in that program, they may provide proof of GPA from that degree in lieu of the high school diploma.
2. Job duties require specific knowledge and training in general business.
3. Have a minimum of two years of healthcare administration or relevant experience.

Technical Skills:

1. Ability to prepare more complex documents in Microsoft Word, including creating tables, charts, graphs and other elements.
2. Ability to use Microsoft Excel to review and compile data, including the use of formulas, functions, lookup tables and other standard spreadsheet elements.
3. Ability to create basic presentations in Microsoft PowerPoint.

Licenses & Certifications: None required.

Communications Skills:

1. Job duties require the compilation of information prepared in effective written form, including correspondence, reports, articles or other documentation.
2. Effectively conveys technical information to non-technical audiences.

Physical Demands: The physical demands here in this job description are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this position, the employee is regularly required to sit and use repetitive hand movement to type and grasp. The employee is frequently required to stand or walk; and the employee must occasionally lift and/or move up to 20 pounds.

Pay Scale:

Min Hourly Rate: $21.56

Max Hourly Rate: $29.75