Managed Care Coordinator

The Managed Care Coordinator completes insurance requirements and provides case management as needed for services performed in various patient seeing settings. The individual obtains and provides insurance benefit information to patients and patient care departments. The Managed Care Coordinator assists patients and providers with developing strategies for alternative options for non-covered services by communicating with the provider, patient, insurance carrier and Patient Assistance Counselor.

ESSENTIAL JOB FUNCTIONS

• Completes insurance managed care requirements for services ordered and/or provided by health system providers.
• Monitors services requiring case management by reviewing medical records, patient appointments and communicating with patients, patient care providers and insurance companies to ensure specific coverage requirements are met.
• Contacts patients to obtain insurance information, communicate expected cost estimate information, and other care related information to complete managed care requirements.
• Reviews applicable schedule(s) and verifies and updates patient insurance eligibility for each appointment.
• Reviews patient account for Patient Responsibility balances and counsel’s patient for expected payment.
• Reviews applicable schedule(s) to verify Prior Authorization existence, accuracy and completion and notifies/obtains missing information from patient care department as necessary.
• Documents interactions with patients via phone or in person and defines the action(s) taken for the purpose of recording these encounters for future reference.
• Communicates with patients and patient care staff regarding insurance coverage limitations and/or requirements to ensure the communication of any issues with internal and external customers regarding services provided throughout the health system.
• Assists patients, staff and outside providers with appeals and requests for retrospective referrals, prior authorizations and denied claims to exhaust all efforts to obtain reimbursement and provide high quality customer service.
• Assists in coordination, training of prior authorization requirements, education and communication of managed care requirements to patients, physicians and employees to allow for maximum reimbursement of services provided.
• Refers to Patient Assistance Counselors for underinsured/uninsured patients and/or point-of-service pre-payment required services to determine if the patient is eligible for assistance and obtain payment prior to services being received, when applicable, to help manage the organizations bad debt.
• Regular attendance is required to carry out the essential functions of the position.
• Reviews and meets ongoing competency requirements of the role to maintain the skills, knowledge and abilities to perform, within scope, role specific functions.

JOB QUALIFICATIONS

EDUCATION

For positions requiring education beyond a high school diploma or equivalent, educational qualifications must be from an institution whose accreditation is recognized by the Council for Higher Education and Accreditation.

Minimum Required: High school diploma or equivalent. Successful completion of a medical/dental terminology and an anatomy & physiology course, per departmental procedures, within one year of hire.

EXPERIENCE

Minimum Required: Two years’ experience in a medical/dental business office or health care setting. Prior experience should include working with and obtaining insurance eligibility and benefit information.

CERTIFICATIONS/LICENSES

The following licensure(s), certification(s), registration(s), etc., are required for this position. Licenses with restrictions are subject to review to determine if restrictions are substantially related to the position.

Minimum Required: Basic Life Support (BLS) certification awarded within 90 days of hire.

Equal Opportunity Employer