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Managed Care Specialist

Company: NorthEast Provider Solutions Inc.

City/State: Valhalla, NY

Category: Clerical/Administrative Support

Department: Managed Care-WMC Health

Union: No

Position: Full Time

Hours: mon-fri 40 hours

Shift: Day

Req #: 43573

Posted Date: Jul 31, 2025

Hiring Range: $31.68 - $39.83

External Applicant link (https://pm.healthcaresource.com/cs/wmc1/#/preApply/29996) Internal Applicant link

Job Details:

Job Summary:

The Managed Care Specialist under the direction of the Senior Director of Managed Care will assist in working with the participating managed care payers on escalated managed care contractual issues on behalf of WMC Health Network for the Hospital’s, Physician Groups and Ancillary Providers. The incumbent will also assist with completion of single case agreements and settlements with both participating and nonparticipating managed care payers. Responsibilities

+ In coordination with the Senior Director of Managed Care, will escalate to the managed care organizations contractual rate and language issues for the WMC Health Network for the Hospital’s, Physician’s and Ancillary Agreements.

+ Responsible to maintain current credentialing status for all Hospital’s and ancillary facilities within the WMC Health Network.

+ Negotiates financially equitable single case agreements with out of network managed care organizations.

+ Assists in completion of settlements with both participating and non- participating managed care payers.

+ Assists in identifying, prioritizing, and arranging discussions with non-participating payers requesting a participating agreement with the WMC Health Network.

+ Maintains current grids for contractual rates and key language items for the network.

+ Communicates with other departments within the WMC Health Network of ongoing and completed contracts with the managed care payers.

+ Assists with scheduling and maintaining Joint Operation Committee meetings with the managed care payers as requested by senior leadership.

+ Other job duties as assigned.

Qualifications/Requirements:

Experience:

Minimum of 1-3 years of experience in a Healthcare setting, required. Minimum One year in a managed care contracting setting, required. Basic knowledge of reimbursement methodologies, such as MSDRG, APR DRG, CPT-4, HCPCS, UB04 and NYS regulations as they relate to Managed Care Organizations.

Education:

Associates degree required, Bachelor’s degree preferred in Business, Finance, or a related field.

Licenses / Certifications:

N/A

About Us:

NorthEast Provider Solutions Inc.

Benefits:

We offer a comprehensive compensation and benefits package that includes:

+ Health Insurance

+ Dental

+ Vision

+ Retirement Savings Plan

+ Flexible Savings Account

+ Paid Time Off

+ Holidays

+ Tuition Reimbursement

External Applicant link (https://pm.healthcaresource.com/cs/wmc1/#/preApply/29996) Internal Applicant link

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