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 patient’s 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.
• Send notification of admission for urgent admissions.
• 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.
• Collects detailed information of trauma admissions (motor vehicle accident, personal injury, and/or worker’s compensation) to determine accident-related liability.
• Appropriately codes insurance plans in EPIC system for billing purposes.
• Work directly with insurance companies, the denial coordinator and the clinical staff and/or provider to supply necessary information to appeal denied claims and/or authorization requests as applicable
• Appropriately code insurance plans within EPIC system for billing purposes.
• Provide backup support for other Managed Care coordinators within the Centralized Managed Care & Price Estimates department.
• For self-pay patients, complete duties associated with financial assistance determinations such as above/below the line. Including connecting patients with necessary social work or financial counseling to assist in the coverage process.
• Complete necessary forms prior to upcoming procedures, admissions, and/or appointments (i.e. Non-Covered Charges Form (NCCF), Advanced Beneficiary Notification (ABN) or Patient Financial Estimate (FE)) as required

Patient Liability Estimates:

• Review work queue for patients that need an estimate created
• Document information based on department protocols in the Epic referral shell
• Create a Patient Liability Estimate
• Complete accurate pre-registration via phone as applicable

Customer Service:

• At all times must exemplify high quality customer service to both external customers as well as internal customers that meets or exceeds the service standards as set by OHSU. This duty includes prompt and professional communication efforts, high level conflict resolution, flexible coverage of internal service needs, continuous application of process improvement methods and skills, crisis management, & developing a standard complaint process for process improvement.

Contact the patient prior to service to inform them of their estimate and collect any pre-payments at that time

Work directly with the patients and clinical team to ensure patient is knowledgeable and understands their insurance benefits and/or financial obligations.

Education: High School Diploma or equivalency

Experience: One year of experience in a medical office and/or medical billing setting, including high-volume direct patient contact.  Must have demonstrable record of reliable attendance, exemplary customer contact skills, punctuality, and proven successful performance at past and present employers. 

The candidate must have a thorough knowledge of managed care policies and procedures, as well as authorization and referral processes in EPIC. 

The candidate must have a thorough knowledge of verifying medical insurance including worker’s comp and third party liability. 

Candidates will have demonstrated advanced managed care user skills. 

Experience with electronic scheduling, managed care websites and electronic medical record systems.

Experience:

Minimum of six months experience as a registrar at OHSU and be able to demonstrate an accuracy rate of 98% or greater. As a registrar must be meeting/exceding all other individual performance standards in a sustained manner.

Knowledge of Medicaid Eligiblity guidelines