Managed Care Coordinator/Insurance Verification & Patient Estimates Specialist (PAS Resource Specialist)
Oregon Health & Science University
Pay Range
Base pay range: $25.86/hr - $34.95/hr
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 role 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. The role is responsible for obtaining and/or verifying prior authorizations, verifying benefits, creating cost estimates, contacting patients to provide estimates, offering pre-service payment opportunity and collecting pre-service payments for visits, treatments, procedures and/or hospital admissions. This position also provides guidance to other staff in patient liabilities, health care contract terms, complex patient referrals, and other managed care issues.
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.
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 provide clinical review and obtain length of stay.
For routine admissions, confirm that the authorizations and/or PCP referrals cover the designated admission. If authorizations and/or PCP referrals are not noted in the system, contact 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.
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 in resolving patient concerns and managed care related issues.
Collect detailed information of trauma admissions (motor vehicle accident, personal injury, and/or worker’s compensation) to determine accident‑related liability.
Appropriately code 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.
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. Include 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.
Work directly with the patients and clinical team to ensure patient is knowledgeable and understands their insurance benefits and/or financial obligations.
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
As assigned by leadership to support the CMC department.
Required Qualifications
Experience
One year of experience in a medical office setting, including high‑volume direct patient contact, scheduling of appointments and may require experience obtaining managed care authorizations (dependent on position description). 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
Thorough knowledge of PAS policies and procedures. Demonstrated advanced PAS user skills and extensive knowledge of integrated care at OHSU.
Thorough knowledge of managed care policies and procedures, as well as authorization and referral processes in EPIC.
Thorough knowledge of verifying medical insurance including worker’s comp and third party liability.
Demonstrated advanced managed care user skills.
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 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. Reviewed regularly as a team and individually.
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 between 7:00am – 5:30pm.
Work location: Downtown Portland (Fifth Avenue Building)/Teleworking. Must be able to share office space with other coworkers and able to multi‑task in a high‑volume environment.
Equal Opportunity Statement
Oregon Health & Science University values a diverse and culturally competent workforce. We are proud of our commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status. Individuals with diverse backgrounds and those who promote diversity and a culture of inclusion are encouraged to apply. To request reasonable accommodation contact the affirmative action and equal opportunity department at 503‑494‑5148 or aaeo@ohsu.edu.