Position Summary:
New Horizons Child and Family Institute is is seeking a sharp, detail-oriented, and highly assertive Behavioral Health Single Case Agreement (SCA) Specialist. In this role, you will be the primary liaison between our clinical team and commercial insurance payors. Your main objective is to secure patient-specific, out-of-network contracts (SCAs and LOAs) that grant our patients in-network cost-sharing benefits. This role requires an administrative powerhouse who understands how to leverage medical necessity data to negotiate fair reimbursement rates and champion patient access to specialized care.
Key Responsibilities
- Contract Negotiation: Initiate, negotiate, and finalize Single Case Agreements (SCAs) and Letters of Agreement (LOAs) with major commercial insurance companies.
- Payer Liaison: Serve as the main point of contact for insurance case managers, medical directors, and member services to navigate complex out-of-network authorizations.
- Documentation Packaging: Review and organize clinical documentation provided by our therapists/clinicians to construct compelling arguments for medical necessity and continuity of care.
- SCA Tracking & Auditing: Manage the full lifecycle of agreements, including monitoring authorization statuses, tracking contract expiration dates, and securing renewals before patient care lapses.
- Claims Resolution: Audit incoming insurance payouts to ensure they strictly match the negotiated SCA fee schedules; identify, appeal, and resolve underpayments or wrongful denials.
Required Technical Skills & Qualifications
- Proven SCA Experience: Minimum of 2+ years of direct experience initiating, negotiating, and executing SCAs/LOAs specifically for behavioral health, mental health, or substance abuse facilities. (Generic medical billing experience will not be considered).
- Out-of-Network Navigation: Demonstrated expertise navigating out-of-network (OON) insurance verification, obtaining authorizations, and managing the unique rules of commercial payers (e.g., Optum, Anthem Blue Cross, Aetna, Cigna, and Northern California Kaiser networks).
- Behavioral Health Coding Mastery: Advanced knowledge of mental health CPT codes (e.g., 90846, 90834, 90837, 90847) alongside current ICD-10 diagnostic codes.
- Rate Negotiation Tactics: Experience countering low insurance rate offers using data-driven arguments, referencing Fair Health data, or UCR (Usual, Customary, and Reasonable) geographic charges.
- Utilization Review Frameworks: Functional understanding of clinical necessity criteria to effectively package clinical notes for insurance case managers during the contract request phase.
- EHR & Billing Software Proficiency: Hands-on experience with electronic health records (EHR) and clearinghouses (e.g., SimplePractice, TherapyNotes, Jane App, Availity, or Optum Provider Express) to track claims and input specialized fee schedules.
- Regulatory Awareness: Familiarity with California healthcare regulations regarding continuity of care, timely access to care, and the No Surprises Act.
Preferred (Bonus) Qualifications
- Existing professional relationships or direct contacts within the utilization review or contracting departments of Northern California commercial insurance payers.
- An Associate’s or Bachelor’s degree in Healthcare Administration, Health Information Management, or a related field.
- Certified Professional Coder (CPC) or Certified Medical Reimbursement Specialist (CMRS) designation.
Compensation & Benefits
Note: The final hourly rate offered within this range will be determined by the candidate's specific depth of out-of-network contract negotiation experience, familiarity with Sacramento-area insurance networks, and mastery of behavioral health electronic health record (EHR) systems.
- Base Pay: $30.00 – $36.00 per hour
- 401(k) retirement savings plan with a company match
- Accrued Paid Time Off (PTO) plus paid annual holidays
- Paid sick leave in strict compliance with California and Sacramento ordinances
- Continuing education reimbursement with prior approval from Director
Pay: $30.00 - $36.00 per hour
Benefits:
- 401(k)
- 401(k) matching
- Flexible schedule
- Paid time off
Work Location: Remote
