Managed Care Representative I

1 month ago

Greenville, United States Physicians East Full time
Job DescriptionJob Description

Job Title: Managed Care Representative I

FLSA Status: Non -Exempt

About us

Physicians East, P.A.is a team of skilled healthcare professionals united to meet the challenge of delivering quality, cost-efficient, comprehensive healthcare to the people of Eastern North Carolina.

Location & commitments

FT/PT/Temp/PRN role based at our Greenville (other) location, Monday-Friday, 8a.m. – 5 p.m. Additional hours may be required to meet the needs of the business. Weekend work is rare but can occasionally be necessary.


Supervision Received: Reports to Operations Manager.


Supervision Exercised: None.


Typical Physical Demands:

Requires sitting for long periods of time. Working in office environment. Some bending and stretching required. Working under stress and use of telephone, fax machine and copier required. Manual dexterity required for use of calculator and computer keyboard.


Typical Working Conditions:

Work is performed in an office environment. Extensive telephone contact with insurance companies, medical facilities, patients, and internal staff.

About the role

The Managed Care Representative I position is responsible for maintaining incoming and outgoing authorizations and referrals for multiple departments and specialties within Physicians East. Managed Care Representatives are responsible for reviewing Request for Authorization forms and ensuring that Orders are in the patient’s charts as well as the diagnosis is present on the form, prior to contacting the Insurance Company. Managed Care Representatives review insurance and check to make sure it is active, contacts the insurance company to verify benefits and ask if Authorization is needed for a procedure, drug, or surgery. If Authorization is needed, the Managed Care Representative is responsible for recording this along with any needed reference information and submitting the form to the appropriate person/department. Managed Care Representatives are required to document forms completely and appropriately if denials are received.

Responsibilities:

GENERAL DUTIES

  • Maintain & process incoming and outgoing authorizations for assigned department(s) and help with STATS and authorizations for team members during times out of the office.
  • Communicate with Providers and Clinical team when orders are not in and/or additional information is needed to submit for authorization.
  • Research “Non-authorized” denials and obtain retroactive authorizations when applicable.
  • Communicate with scheduling team(s) when procedures have not been approved for preauthorization. Provide inter-departmental authorizations and internal referrals.
  • Obtain prior approval authorizations for specialists performing test or procedures. **Clinical staff or scheduling personnel are responsible for notifying the Managed Care Representative when procedures or outside testing is needed.
  • Obtain in-patient authorization or precertification for hospital admissions.
  • Notify appropriate personnel of any changes required by insurance companies.
  • Route applicable procedures to the Cost Estimates team.

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