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. It supports the OHSU systems and operations of ambulatory practices, professional services and hospital departments. The coordinator 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 provide clear and accurate information regarding patients, financial obligations related to their visits, treatments, procedures, and/or hospital admissions. Responsibilities include obtaining and/or verifying prior authorizations, verifying benefits, creating cost estimates, contacting patients to provide estimates, offering pre‑service payment opportunities, and collecting pre‑service payments for visits, treatments, procedures, and/or hospital admissions.

The role also provides guidance for other staff regarding patient liabilities, health care contract terms, complex patient referrals, and other managed care issues. The incumbent possesses extensive knowledge of managed care and insurance verification processes in both ambulatory and inpatient settings, including insurance eligibility, benefits verification, and authorization requirements. They are proficient with the Epic system and current best‑practice referral and prior authorization workflows, serving as backup to the Centralized Managed Care & Price Estimates Department as needed for cross‑coverage of all managed care and insurance verification workflows.

• Review incoming referral orders to assess patient 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 managed care arrangements. Document details related to liability insurance (e.g., motor vehicle accident, personal injury, or worker’s compensation) to determine third‑party liability.
• Obtain benefit information including current eligibility, deductible or co‑pays, co‑insurance, stop‑loss 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, provide admit information and set up authorizations and/or PCP referrals. Contact care‑management to obtain clinical review and length of stay.
• For routine admissions, confirm that authorizations and/or PCP referrals cover the designated admission. If not noted, contact the Managed Care Coordinator from the specialist’s office to follow up with the designated insurance company.
• 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.
• Maintain current information on managed care insurance plans and serve as a liaison and information resource for patients, referring physician offices, and other OHSU staff. Apply problem‑solving and negotiating skills to resolve patient concerns and managed care related issues.
• Appropriately code insurance plans in EPIC for billing purposes.
• Work directly with insurance companies, the denial coordinator, and clinical staff and/or providers to supply necessary information for appealing denied claims and/or authorization requests as applicable.
• Provide backup support for other Managed Care coordinators within the…