Managed Care Services Rep

Site: Mass General Brigham Incorporated

Mass General Brigham relies on a wide range of professionals including doctors nurses business people tech experts researchers and systems analysts to advance our mission. As a notforprofit we support patient care research teaching and community service striving to provide exceptional care. We believe that highperforming teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

This is a 100% work from home (remote) position. Under general direction of the Manager the incumbent is primarily responsible for working collaboratively with practices physicians and patients to ensure that required Managed Care insurance referrals are obtained and appropriately recorded in Epics Referral Management system prior to scheduled patient visits. The Referral Services Representative will communicate with patients physicians and payor representatives as necessary in order to accomplish this and obtain the appropriate referral authorizations for Outpatient visit utilizing available management reports to followup on unresolved issues and denied claims. The Referral Services Representative is responsible for performing various administrative and clerical duties required to support these functions and on an asneeded basis may be required to perform other tasks.

Principal Duties and Responsibilities:
Patient Service Center is a centralized call center. Incumbents receive calls place calls and obtain/generate insurance referrals.

responsible for working collaboratively with Mass General Brigham practices to obtain insurance referrals for specialty services prior to scheduled visits by effectively communicating with payers to submit track followup and obtain insurance referrals in a timely manner via websites software fax and telephone. Duties include working EPIC work queues and checking information in EPIC to determine if a valid referral for internal external and/or incoming visits exists. If a valid referral is in EPIC the incumbent will be responsible for linking the referral to the appropriate visit(s). For visits without a valid referral in the EPIC the incumbent will use various payer technologies to obtain referral and authorization numbers for Mass General Brigham primary care practices and for specialty visits by contacting external PCPs to obtain referral numbers. Followup requires entering information into EPIC.

for documenting and tracking the number of referrals that are deferred generated and obtained. Followingup with practices who do not immediately issue an insurance referral noting the reason for the delay and documenting when referrals are denied. Interfacing with practices and patients to report referral information. Complying with Patient Service Center standards for productivity accuracy quality and customer service.


for verifying and updating patient registration information including insurance demographic and patient data needed to perform referral management functions. Works collaboratively with the Registration Department to resolve registration issues. Responds to questions regarding open accounts or managed care/insurance issues.

with patients will be necessary when information required to obtain an insurance referral cannot be completed. This may include working with a patient to: 1) to confirm and/or facilitate PCP assignment 2) resolve insurance discrepancies 3) reverify insurance information with the patient correcting information in Mass General Brigham systems and then resubmitting referral requests to the insurance company.

for communicating benefit plan information to patients when necessary and followingup with insurance companies and/or patients to ensure information has been updated with payers.

with all Mass General Brigham Support Staff and leadership to prioritize and facilitate referral processes to maintain integrity of service standards.

a clear understanding of the various payor referral and authorization process and requirements for departmental policies and procedures.

as a resource to providers support staff and patients regarding the referral and authorization process; researches questions thoroughly and assists with interpretation of health plan guidelines.

inquiries from customers investigates and disseminates information to requestor and wider audiences as appropriate.

EPIC work queues to review billing rejections and resolve insurance issues to maximize reimbursement. This includes but is not limited to obtaining retroactive referral numbers for bills that were denied for no referral.

need for escalation of issues or problems to appropriate supervisor or manager.

other duties as assigned.
Obtain preauthorization from insurance companies for various medical procedures surgeries and diagnostic tests.

Collaborate with healthcare providers including physicians and nurses to ensure accurate and complete documentation for insurance claims.

Communicate with insurance companies to resolve any coverage issues or denials advocating for the best interests of the hospital and patients.

Educate patients about their insurance benefits coverage limitations and financial responsibilities.

Assist patients in understanding and navigating the insurance claim process including explanation of benefits (EOB) and billing statements.

Process and submit insurance claims accurately and in a timely manner adhering to industry regulations and guidelines.

Qualifications:

• High school diploma or equivalent required. Associate or Bachelors Degree preferred.
• Minimum of 3 years of Registration Scheduling and Insurance Authorization experience within a healthcare setting is required
• An effective team player with strong interpersonal skills
• Demonstrated ability to work and make decisions in a fast paced high volume work environment
• Proficient with office software packages such as word processing and spreadsheets including Epic and any other system the PSC may be utilizing
• Call Center environment experience
• 5 years of customer service experience is required
• Experience with EPIC and medical office workflows required
• Proficient computer skills; Experience with Microsoft Office applications (Outlook Word and Excel)
  
  

Skills/Abilities:

• The ability to set prioritize and follow through with responsibilities
• Ability to exercise appropriate judgment with sensitive and confidential material
• The ability to successfully resolve conflict
  Ability to communicate and interact effectively with all levels of hospital personnel
  
• Ability to maintain confidentiality with regard to all phases of the work
• Ability to withstand the pressure of continual deadlines and receipt of work with variable requirements

• Ability to concentrate and maintain accuracy in spite of frequent interruptions
• Ability to be courteous tactful and cooperative throughout the working day
• Ability to use judgment in carrying out all phases of the work
• Ability to use standard office equipment including computers photocopy and facsimile machines and readers/printers
• Excellent Customer Service Skills demonstrated ability to use appropriate judgment independent thinking and creativity when resolving customer issues.

Remote

399 Revolution Drive

40

Regular

Day (United States of America)

Mass General Brigham Incorporated is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race color religious creed national origin sex age gender identity disability sexual orientation military service genetic information and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process to perform essential job functions and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973 the Vietnam Veterans Readjustment Act of 1974 and Title I of the Americans with Disabilities Act of 1990 applicants who require accommodation in the job application process may contact Human Resources at (857)2827642.

Mass General Brigham Competency Framework