Managed Care Specialist in El Segundo, CA at Pipeline Health Los Angeles

Date Posted: 4/28/2021

Job Snapshot

Job Description

Avanti Hospitals, Corporate Office

Job Title: Managed Care Specialist 

City: El Segundo / State: California    

Managed Care

Day Shift

From 9:00 AM

To 5:30 PM


Job Description and Job Responsibilites

Job Title:  Managed Care Specialist

Job Summary: 

Responsible to assist Manager with daily operations of the Managed Care areas including MSO audit preparation, financial review, membership and claim data analysis and other Managed Care activities.   Reports to Manager, Managed Care.

Essential Job Duties:  

  • Demonstrates the ability to communicate effectively both verbally and written to staff and upper management.
  • Demonstrates the ability to research and coordinate information and distribute accordingly
  • Demonstrates the ability to prioritizing tasks and job assignments
  • Demonstrates and understands the various procedures within the department
  • Reviews daily MSO claims adjudication for accuracy, timely filing, authorization status, payment responsibility, other parameters.
  • Reviews and analyzes Risk Pool reports, claim data and trend data, reconciles data to ensure results are being achieved.
  • Researches, analyzes and recommends resolution of claim issues, eligibility and billing questions and other practices.
  • Monitors Daily Census Reports
  • Supports the execution of letter of agreements with hospitals, physician groups, ancillary providers and other vendors to build and maintain a cost-effective, accessible provider network.
  • Performs other related duties as directed by Manager.
  • Maintain and foster a collaborative relationship with MSO, Payors, medical groups, ancillary providers, Case Management, CBO and other hospital departments.  
  • Demonstrates the ability to prepare work schedule and assignments and performs the tasks as assigned.
  • Able to perform difficult and complicated procedures involving independent judgment and planning.

Job Requirements


  • Degree in business accepted and or years of experience required
  • Prefer at least 1 year in Managed Care management
  • Computer skills required
  • Knowledge in managed care laws, ERISA and Knox-Keene act preferred

Licensure/Certifications:  N/A