Managed Care Specialist

This is a fully remote position, open to applicants in Pennsylvania.

📋 Description

• Conduct initial pre-certification, concurrent, and discharge review calls to managed care organizations for Caron inpatient programs.

• Perform utilization reviews based on benefit verification through verbal, written, faxed communication, or managed care portal access.

• Send ACT 106 prescriptions and necessary treatment forms to managed care companies for authorizations and follow-up documentation.

• Fulfill medical record requests related to authorization and discharge inquiries.

• Draft appeal letters of medical necessity upon request.

• Accurately record authorizations or denials and the reasons for denials in the contact log.

• Complete documentation in Aura to ensure accurate discharge claims, billing, and statistical reporting.

• Participate in weekend precertification coverage on a rotating basis, including holidays.

• Uphold confidentiality and professionalism at all times.

• Facilitate peer-to-peer reviews for contracted insurers.

• Ensure proper consent to release information to insurance is accurate and reflects the funding source.

• Verify that medical level-of-care assessments are accurate and completed at the time of admission.

• Maintain clinical-record documentation current and reflective of the prevailing level of care.

⛳️ Requirements

• CAC or BA in Human Services or nursing experience is required.

• A minimum of 1 year of customer service experience in a healthcare setting is required.

• Proficiency in computer skills and working knowledge of Microsoft Office (Outlook, Word, and Excel) or similar software is required.

• Excellent verbal and written communication skills are essential.

• Knowledge of addiction, 12-step programs, and ASAM level of placement criteria is required.

• Ability to report to work promptly and regularly.

• Capability to achieve customer satisfaction for both internal and external clients.

• Understanding of the Treatment Planning Process, documentation, and confidentiality regulations.

• Familiarity with medical necessity criteria, documentation, and confidentiality regulations.

• A private workspace to handle confidential phone calls is necessary.

• Ability to communicate verbally for 85% of the workday.

• Ability to sit for 90% of the workday.

• Ability to type for 85% of the workday.

• Preferred: 2 years of continuous sobriety if in recovery.

• Willingness and capability to rotate weekend precertification coverage, including holidays.

🏝️ Benefits

• Generous paid time off.

• Company-paid life and disability insurance.

• Opportunities for professional growth and development.

• Tuition reimbursement.

• Competitive 401(k) plan.

• Medical, dental, and vision plans.

• A diverse and inclusive work environment.

• Emphasis on teamwork, compassion, and dedication to the mission.

• Comprehensive training provided.

• Commitment to work-life balance.