Managed Care/Credentialing Specialist

• Monitor Insurance Contracts and process re-enrollment for GCC, including Medicare, Medicaid, Medicaid Managed Care, Medicare Advantage plans, and Commercial plans. Negotiate updated rate increases with MCOs as needed. Track contracts progress of rate increases, addendums, and dates of execution on the contract tracker spreadsheet. 
• Work with Contract Manager and Director of Legal Services when Memorandum of Understanding when received by Insurance companies.
• Work with LPHA's to complete enrollment with Medicaid, Medicaid MCO, Medicare, and 3rd Party insurance.
• Maintain the Center's and performing providers' National Provider Identifiers.
• Execute new contracts, addendums as well as single case agreements as necessary.
• Review Medicaid Revenue reports through State Data Warehouse Reporting Services.
• Coordinate with Human Resource Department dates of expiration for staff that have a license or certification as it relates to billing.
• Participate in State and Agency Webinars as it relates to Manage Care Contracts.
• Coordinate with Provider Representatives of Managed Care and 3rd Party Insurance Companies to schedule quarterly meetings with Reimbursement Department.
• Keep Patient Service Specialist, Eligibility Specialist, and Reimbursement Department informed of all Managed Care, Medicaid, and 3rd Party Insurance of any billing and authorization changes. 
• Understand and assist with posting payments and adjustments as they are received from 3rd Party Payer. This would include transferring or adjusting any applicable fees to the patient's account after full payment from insurance is received.
• Understand and assist with follow-up on all unpaid claims. Claims must be tracked until paid or denied including claims billed but never paid, re-submission of incorrect claims, or mailing paper claims.
• Monitor denial trends and report immediately to the Assistant to the Director of Reimbursement.
• Must have extensive knowledge of 3rd Party Insurance, Medicare, Medicaid, and Medicaid Managed Care billing requirements to include Substance Use billing.
• Demonstrated ability to understand and be familiar with Behavioral Health and Intellectual Developmental Disability billing codes.
• Demonstrated ability to work with web-based portals to retrieve 835 files for payment posting.
• Have knowledge about State Funded Services and their billing requirements. This would include IDD Authority services and TRR Mental Health and Substance Use services.
• Monitor and assist with HHSC Service Authorization Requests Forms and Texas Resilience and Recovery requested services.
• Understand and assist with reports on adjustments, and possible write-offs and help stay apprised of key Revenue Cycle Management indicators.

• Receives supervision from Assistant to the Director of Reimbursement Services.

• Requires high school diploma or equivalent.
• Requires a valid Texas driver's license and be an insurable driver.
• Requires five (5) years of experience in the Behavioral Health field, insurance, and credentialing, managing patient accounts, insurance verification and benefits, and claims processing.
• Preferred ten (10) years of experience in the Behavioral Health field, insurance verification and credentialing, and managing patient accounts and benefits.
• Preferred college degree.

• Healthcare Insurance verification, billing practices, pre-authorization requirements for Medicaid, Medicaid MCO, Medicare, Medicare Advantage Plans, and 3rd Party Insurance.
• Knowledge of credentialing and contracting requirements for Managed Care, Medicaid, Medicare, and 3rd Party Insurance.
• Proficient in Windows Office and working in web-based portals.
• Prefer experience in Mental Health, Substance Use Disorders, and/or Intellectual Disability fields.
• Requires experience in working successfully in a team approach.

• Proficient in all phases of insurance contracting and credentialing.
• Excellent organizational skills.
• Excellent time management, multi-tasking, critical thinking, and accuracy skills.
• Good communication skills when talking with Insurance companies and their representatives concerning payments, denials, and appeals.
• Demonstrated ability to work in Center's Electronic Health Record and billing system (SmartCare) as well as, Managed Care and Commercial Insurance portals including TMHP and CARE.
• Must be self-motivated and can work in a team environment.
• Will be knowledgeable of all aspects of State, Medicaid, Medicaid MCO, 3rd Party Insurance, and Medicare contracts and ensure adherence to those requirements; will be familiar with and adhere to the Center's stated policies and procedures.

• Non-exempt under the Fair Labor Standards Act.

• Standard office environment.
• Occasional travel to other Center location sites is required.
• May require irregular work hours.

• Work Team - Display professionalism and treat all team members with consideration, respect, and courtesy.
• Customer Service - Must always provide excellent Customer Service to patients, outside agencies, and team members throughout the Gulf Coast Center.
• Credentialing - Must maintain or enroll provider's data in CAQH. Complete online or manual credentialing applications for Center LPHA's and MDs with Medicaid, Medicare, Medicaid MCOs, and any 3rd Party Insurance providers. Keep current any Roster of staff certifications required by Managed Care Organizations. Work closely with Managed Care Provider Representatives to review and monitor all credentialing and billing needs.
• Claims processing and Billing - Provide and assist with Center billing to include claims submission and re-submissions, revenue posting, claim denials, and appeals. Monitor and process all Medicaid retroactive billing, communicating with all Center staff when patient's insurance benefits change. Follow all Medicaid, Medicaid MCO, Medicare, and 3rd Party Insurance Billing Guidelines. Submit voucher billing in CMBHS for Substance Use contracted providers.
• Insurance Verification and Pre-Authorizations - Will be responsible to help the Patient Service Specialist and Eligibility Advisor for verification and pre-authorization of services if needed.
• Data Entry - Able to work efficiently and accurately in SmartCare's EHR, including all data entry/claim processing procedures, reading, and monitoring data reports generated by SmartCare. Must be able to work in CMBHS and CARE as needed and familiar with maneuvering in Data Warehouse to review reports as they pertain to billing and reimbursement.
• Training - Maintain as current, all levels of training as directed by GCC policy as well as those outlined in the HHSC contract specific to this position.
• Corporate Compliance - Strict adherence to the professional, ethical, and legal requirements set forth in the Center's Business Code of Conduct as well as the Corporate Compliance Plan.
• Other Duties/Special Projects - Attend mandatory program staff meetings.  Assist in and accurately complete special projects as requested by the program manager. Perform other duties as assigned. 

Salary : $1,539 - $1,731