Managed Care Specialist

About the role

The Managed Care Specialist contributes to the Managed Care department by supporting managed care contracting requirements, the provider credentialing process, and maintaining IPA relationships.

Responsibilities

• Handle day-to-day interactions and activities with primary IPA and Health Plans, including:
  • Addressing membership, credentialing, and referral-related issues.
  • Processing and reviewing monthly membership attributions.
  • Analyzing and identifying membership trends for organization-wide communication.
  • Researching, compiling, and drafting responses to Health Plan patient grievances.
  • Reviewing and submitting Health Plan requests for medical records for approval.
  • Coordinating external party requests for remote EMR access and/or medical record retrieval.
  • Facilitating the scheduling of Health Plan contractual audit requests with FHCN staff and departments.
  • Actively participating in Health Plan-based collaborative discussions, trainings, and Community Advisory Committee meetings.
• Produce and validate monthly reporting related to Managed Care department activities, including:
  • Assigned membership trends and market share analysis.
  • Quality Improvement health plan initiatives.
  • Specialist network adequacy and improvement opportunities.
  • Provider credentialing-based activities.
  • Other reporting as determined by business needs.
• Assist Credentialing Specialist(s) with initial credentialing, reappointment, and hospital privileging processes as needed.
• Facilitate the completion of Health Plan and State Sponsored Program enrollments by collecting, assembling, and delivering applications for final review and submission.
• Adhere to the Attendance and Absenteeism Policy, recognizing regular attendance as an essential function of the role. Ability to work at any FHCN location as needed.
• Perform other duties as assigned.

Requirements

• Effective June 1, 2026, all individuals hired must:
  • Possess work-related skills at a higher level than high school completion, including formal written and verbal communication, computational, computer, mathematical, and technical skills.
  • Preferred completion of an Associate’s Degree program with a recognized major and a minimum cumulative GPA of 2.5.
  • Proof of high school completion with a minimum overall GPA of 2.5 or completion of General Educational Development (GED) with a minimum overall score of 162.5. Health care-related knowledge, often acquired through trade school, para-professional, or certificate programs, is preferred.
  • If an individual has completed a higher-level degree with a stronger GPA, they may provide proof of GPA from that degree in lieu of the high school diploma.
• Minimum of two years of healthcare administration or relevant experience.
• Specific knowledge and training in general business.

Skills

• Ability to prepare complex documents in Microsoft Word, including tables, charts, graphs, and other elements.
• Proficiency in Microsoft Excel for reviewing and compiling data, including formulas, functions, lookup tables, and other standard spreadsheet elements.
• Ability to create basic presentations in Microsoft PowerPoint.
• Strong written communication skills for compiling reports, correspondence, and other documentation.
• Ability to convey technical information effectively to non-technical audiences.

Physical Demands

The physical demands described here are representative of those required to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions.

• Regularly required to sit and use repetitive hand movements for typing and grasping.
• Frequently required to stand or walk.
• Occasionally required to lift and/or move up to 20 pounds.

Pay

Hourly rate range: $21.56 – $29.75.