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.
Function/Duties of Position:
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.
- Contact the patient prior to service to inform them of their estimate and collect any pre-payments at that time.
Other duties as assigned.
Required Qualifications:
- One year of experience in a medical office setting in a managed care position, including high-volume scheduling of appointments, multi-line phone system, medical terminology, verifying medical insurance and obtaining managed care authorizations; OR
- One and a half years of work experience in a high-volume direct public contact position and 6 months experience in a medical office setting.
Knowledge, Skills, and Abilities
The candidate must have a thorough knowledge of PAS policies and procedures.
Candidates will have demonstrated advanced PAS user skills as well as extensive knowledge of integrated care at OHSU.
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.
- Experience with electronic scheduling, managed care websites and electronic medical record systems.
Basic computer skills, including MS Word, Excel and Access, OHSU Epic skills and online resource use knowledge.
Excellent communication skills, both written and verbal.
Demonstrated knowledge of managed care and insurance verification policies and procedures including appropriate timelines, paperwork, regulations, communication and follow-up are also required.
Demonstrated efficiency, problem solving and negotiation skills in resolving patient concerns and managed care/insurance related problems.
Must meet Department performance standards measuring efficiency, production, timeliness and accuracy. This will be reviewed on a regular basis both as a team and as an individual.
Ability to multi-task in a high-volume situation.
Strong attention to detail and processes.
Ability to work autonomously, with a high level of accuracy, speed and exhibit a willingness to work with deadlines.
- Strong customer service orientation.
- Demonstrated effectiveness in confrontational customer interactions.
Preferred Qualifications:
- High School Diploma or GED.
- Excel skills and knowledge preferred.
Additional Details:
Work Schedule: Monday - Friday, 8-hour shift during operational hours 7:00am - 5:30pm.
Work location: Remote/Downtown Portland (Fifth Avenue Building).
Must be able to share office space with other coworkers and able to multi-task in a high-volume environment.
Benefits
- Healthcare for full-time employees covered 100% and 88% for dependents.
- $50K of term life insurance provided at no cost to the employee.
- Two separate above market pension plans to choose from.
- Vacation - up to 200 hours per year dependent on length of service.
- Sick Leave - up to 96 hours per year.
- 9 paid holidays per year.
- Substantial Tri-Met and C-Tran discounts.
- Employee Assistance Program.
- Childcare service discounts.
- Tuition reimbursement.
- Employee discounts to local and national businesses.
We are Oregon's only public academic health center. In addition to caring for patients, we lead groundbreaking research. We also train the next generation of health care professionals. As Portland's largest employer, we give you opportunities to learn and advance in a system of hospitals and clinics across Oregon and Southwest Washington.
All are welcome. OHSU welcomes people of all ages, ethnicities, genders, national origins, religions and sexual orientations. We are striving to build an anti-racist, multicultural institution and encourage people with diverse backgrounds to apply. To request reasonable accommodation, contact askhr@ohsu.edu
