Consumer Benefits Specialist

JOB DESCRIPTION

TITLE:                                   Consumer Benefits Specialist

CLASSIFICATION:            Administrative Specialist IV

SALARY RANGE:               $33,800-51,431

SUPERVISOR:                     Director of Health Information Management

DEFINITION:

The Consumer Benefits Specialist is responsible for coordinating consumer benefits management, representative payee oversight, utilization review activities, authorization management, and reimbursement optimization across Carastar Health programs. The Consumer Benefits Specialist serves as the central point of accountability for ensuring consumers maintain appropriate funding sources necessary to support treatment services while maximizing reimbursement opportunities and maintaining compliance with payer, regulatory, and accreditation requirements.

DESCRIPTION OF DUTIES:

Monitor consumer eligibility for Medicaid, Medicare, SSI, SSDI, Veterans Benefits, and other funding sources.

Coordinate applications, renewals, recertifications, and reinstatements of consumer benefits.

Maintain tracking systems to ensure benefits remain active and interruptions in coverage are minimized.

Coordinate representative payee services and ensure compliance with Social Security Administration requirements and other applicable regulations.

Review consumer account balances and approve monthly consumer fund requests prior to submission to Fiscal Affairs.

Monitor representative payee accounts to ensure appropriate use of consumer funds and maintain required documentation.

Coordinate with Fiscal Affairs to ensure collection of consumer financial obligations and funds owed to Carastar Health.

Monitor consumer accounts to identify reimbursement risks, funding gaps, and opportunities to improve collections.

Conduct utilization reviews to ensure medical necessity, appropriate levels of care, and compliance with payer requirements.

Coordinate prior authorization requests, continued stay reviews, and other payer-required utilization activities.

Communicate with Medicaid, Medicare, managed care organizations, commercial insurers, and other funding sources regarding authorization and reimbursement issues.

Track authorization approvals, denials, and expiration dates to ensure continuity of services.

Assist with appeals, reconsiderations, and recovery efforts related to denied or delayed claims.

Prepare reports related to benefits management, utilization review activities, representative payee services, authorizations, denials, and reimbursement outcomes.

Monitor compliance with Department of Mental Health, Medicaid, Medicare, CCBHC, CARF, and other regulatory or accreditation standards.

Assist with audits, accreditation reviews, and quality improvement initiatives.

Provide education and technical assistance to staff regarding benefits, authorizations, representative payee processes, and reimbursement requirements.

Maintain continuing education by participating in educational opportunities.

Perform other duties as requested by Supervisor.

REQUIREMENTS:

Knowledge of Medicaid, Medicare, SSI, SSDI, and other public assistance programs.

Knowledge of utilization review principles, medical necessity requirements, and payer authorization processes.

Knowledge of representative payee regulations and financial accountability standards.

Knowledge of behavioral health reimbursement systems and funding sources.

Strong analytical, organizational, and problem-solving skills.

Strong attention to detail and documentation skills.

Ability to prepare reports and maintain accurate financial and consumer records.

Experience with electronic health records and Microsoft Office applications.

Ability to communicate effectively with consumers, staff, funding agencies, and external stakeholders.

Ability to drive and work at each location as needed.

Prolonged periods of sitting at a desk and working at a computer.

QUALIFICATIONS

Associate degree in Healthcare Administration, Health Information Management, Business Administration, Social Work, Human Services, Accounting, or a related field, plus three years of progressively responsible experience in utilization review, healthcare reimbursement, benefits coordination, case management, medical billing, or a related healthcare field;

OR

Bachelor's degree in Healthcare Administration, Health Information Management, Business Administration, Social Work, Human Services, or a related field, plus one year of related experience.

Experience working with Medicaid, Medicare, SSI, SSDI, behavioral health services, prior authorizations, and third-party payer requirements preferred.

Experience with electronic health records and healthcare reimbursement systems preferred.

Must hold a valid driver's license and maintain a driving record that is acceptable to Carastar Health's insurance carrier.

Must maintain at least liability coverage on personal vehicles.