Managed Care/Credentialing Specialist

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CENTER JOB TITLE:  Managed Care/Credentialing Specialist

Program:  Reimbursement Department

Employee: Full time - with benefits

Supervisor:   Assistant to the Director of Reimbursement Services


*  Responsible for the Center's enrollment/credentialing of new providers with all Insurance Companies and assist with billing as it relates to Revenue Cycle Management to include:

o  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 MCO's as needed. Track contracts progress of rate increases, addendums, and dates of execution on contract tracker spreadsheet.  

o  Work with Contract Manager and Director of Legal Services when Memorandum of Understanding when received by Insurance companies.

o  Work with LPHA's to complete enrollment with Medicaid, Medicaid MCO, Medicare, and 3rd Party insurance. 

o  Maintain the Center's and performing providers National Provider Identifiers.

o  Execute new contracts, addendums as well as single case agreements as necessary.

o  Review Medicaid Revenue reports through State Data Warehouse Reporting Services.

o  Coordinate with Human Resource Department dates of expiration for staff that have a license or certification as it relates to billing.

o  Participate with State and Agency Webinars as it relates to Manage Care Contracts.

o  Coordinate with Provider Representatives of Managed Care and 3rd Party Insurance Companies to schedule quarterly meetings with Reimbursement Department.

o  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. 

o  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 patient's account after full payment from insurance is received.

o  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 claim.

o  Monitor denial trends and report immediately to Assistant to the Director of Reimbursement.

o  Must have extensive knowledge of 3rd Party Insurance, Medicare, Medicaid and Medicaid Managed Care billing requirements to include Substance Use billing.

o  Demonstrated ability to understand and be familiar with Behavioral Health and Intellectual Developmental Disability billing codes.

o  Demonstrated ability to work with Web based portals to retrieve 835 files for payment posting.

o  Have knowledge about State Funded Services and their billing requirements.  This would include IDD Authority services and TRR Mental Health and Substance Use services.

o  Monitor and assist with HHSC Service Authorization Requests Forms and Texas Resilience and Recovery requested services.

*  Understand and assist with reports on adjustments, 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 Drivers License and be an insurable driver

*  Requires five (5) years experience in Behavioral Health field, insurance, and credentialing, managing patient accounts, insurance verification and benefits, and claims processing.

*  Preferred ten (10) years experience in Behavioral Health field, insurance verification and credentialing, 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 field.

*  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 to include, 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 Center's stated policies and procedures.


*  Non-exempt under Fair Labor Standards Act


*  Standard office environment

*  Occasional travel to other Center location sites 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 MCO's, and any 3rd Party Insurance providers.  Keep current any Roster of staff's 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 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, to include 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.

Trainings   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 program manager.  Perform other duties as assigned. 

Qualified individuals must be able to perform these functions with or without reasonable accommodations as based on ADA requirements.