Managed Care Coordinator​/Insurance Verification & Patient Estimates Specialist; PAS Resource Sp

Department Overview

This position is responsible for managed care, insurance verification and patient price estimate processes within the Centralized Managed Care & Price Estimates (CMC) department. This position supports the OHSU systems and operations of ambulatory practices, professional services and hospital departments. This position works closely with internal and external customers including Intake Coordinators, Clinical Staff, Surgery Schedulers, Care Managers, Financial Counselors, Insurance Companies, PCP Office Staff, and CMC Leadership to ensure patients receive optimal financial services related to their care.

The Managed Care Coordinator and Insurance Verification & Patient Estimates Specialist are an integral part of the CMC team by providing clear and accurate information regarding our patients, financial obligations related to their visits, treatments, procedures and/or hospital admissions. This role is responsible for obtaining and/or verifying prior authorizations, verifying benefits, creating cost estimates, contacting patients to provide estimates, offer pre-service payment opportunity and collecting pre-service payments for visits, treatments, procedures and/or hospital admissions.

This position is also responsible for providing guidance for other staff in the areas of patient liabilities, health care contract terms, complex patient referrals, and other managed care issues.

The incumbent will have an extensive knowledge of Managed Care and Insurance Verification processes in the ambulatory and inpatient setting including but not limited to insurance eligibility, benefits verification and authorization requirements. This role is knowledgeable about the Epic system and current best practice referral and prior authorization workflows. The incumbent is able to provide support and backup to the Centralized Managed Care & Price Estimates Department as needed for cross-coverage for all managed care and insurance verification workflows.

Centralized Managed Care and Insurance Verification

• Review incoming referral orders to assess patient’s needs based on diagnosis, insurance coverage or lack thereof, and previous treatments. Referrals may be received internally via Epic or externally via fax or other methods.
• Verify patient information including demographics, insurance coverage and financial status. Confirm patient eligibility for health care coverage and clarify any managed care arrangements. Document any details related to liability insurance (i.e. motor vehicle accident, personal injury, or worker’s compensation) to determine third party liability.
• Obtains benefit information including current eligibility, deductible or co-pays, co-insurance, stoploss or out of pocket status, authorization requirements, PCP referral requirements, days approved (for routine admissions), and correct billing address.
• Document information based on department protocols in the Epic Referral shell.
• Work closely with referring providers to obtain necessary insurance referrals and authorizations.
• For urgent/emergent admissions, provides admit information and sets up authorizations and/or PCP referrals. Contacts care-management to provide clinical review and obtain length of stay.
• For routine admissions, confirms that the authorizations and/or PCP referrals cover the designated admission. If authorizations and/or PCP referrals are not noted in the system, contacts the Managed Care Coordinator from specialist’s office requesting the admission for follow up with the designated insurance company.
• When appropriate, obtain authorizations for all clinical care, procedures, diagnostic studies, medications, outpatient infusion treatment, and inpatient admissions including notifying insurance upon admission.
• Follow up on all pending authorizations and/or PCP referrals until accounts are secured.
• Maintains current information on managed care insurance plans and serves as a liaison and information resource for patients, referring physician offices, and other OHSU staff. Applies problem solving and negotiating skills in resolving patient concerns and managed care related issues.
• Appropriately codes…