HMO Coordinator
1 week ago
Position Summary
The HMO Coordinator is responsible for managing all aspects of patient insurance authorization, eligibility verification, and communication with Health Maintenance Organizations (HMOs). This role ensures timely approvals, accurate documentation, and effective coordination between clinical teams, payers, and administrative departments to support smooth patient care and reimbursement processes.
Primary Responsibilities
Authorization & Eligibility
- Verify patient insurance coverage, benefits, and plan details prior to admission, during hospitalization, and at discharge.
- Obtain and track initial and concurrent authorizations for inpatient, outpatient, and ancillary services.
- Submit clinical documentation to HMOs and payers to support medical necessity.
- Follow up proactively on pending authorizations, denials, or requests for additional information.
- Serve as the primary liaison between the facility and HMO representatives.
- Communicate insurance requirements and updates to case managers, nurses, physicians, admissions, and billing teams.
- Notify clinical and administrative staff of authorization statuses, limitations, or changes in coverage.
- Collaborate with case management to ensure timely discharge planning, continued stay reviews, and level-of-care approvals.
- Document all insurance communications, authorization numbers, and payer follow-up in the EMR system.
- Maintain accurate logs of insurance activities for audit and compliance purposes.
- Ensure compliance with state and federal regulations, payer guidelines, and facility policies.
- Support appeals processes by gathering required documents and coordinating with case management or billing when claims are denied.
- Inform leadership of any coverage or authorization issues that may affect reimbursement.
- Monitor trends in payer behavior and assist in resolving recurring authorization barriers.
- Assist billing and revenue cycle departments with insurance clarification or documentation retrieval.
Education & Experience
- High school diploma or GED required; associate or bachelor's degree preferred.
- Minimum 1-2 years of experience in healthcare authorizations, case management support, insurance verification, or revenue cycle.
- Experience working with HMOs, PPOs, Medicare Advantage plans, or Medicaid Managed Care organizations strongly preferred.
- Strong knowledge of insurance authorization processes, medical terminology, and healthcare reimbursement.
- Excellent communication skills for interacting with payers, clinical staff, and patients.
- Ability to multitask, prioritize, and work in a fast-paced hospital or healthcare environment.
- Proficiency with EMR systems, insurance portals, Microsoft Office (Word, Excel), and authorization software.
- Strong attention to detail, problem-solving skills, and accuracy in documentation.
- Ability to maintain confidentiality and comply with HIPAA regulations.
- Strong customer service orientation and professionalism.
- Ability to work independently and as part of an interdisciplinary team.
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