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Managed Care Service Representative - 18-00615
Ref No.: 18-00615
Location: Somerville, Massachusetts
Position Type:Right to Hire
Start Date / End Date: 03/15/2018 to 06/14/2018
General Summary/Overview Statement:
Under general direction of the Supervisor the incumbent (MCSR) is primarily responsible for working collaboratively with primary care Practices, specialty care Practices, primary care physicians, referring physicians, and patients to ensure that required referrals are obtained and appropriately recorded in the relevant practice management systems prior to scheduled patient visits.
The MCSR will communicate with patients, physicians and payor representatives as necessary in order to accomplish this, utilizing available management reports to follow-up on unresolved issues and denied claims.
The MCSR is responsible for performing various administrative and clerical duties required to support these functions and, on an as-needed basis, may be required to perform other tasks.
Principal Duties and Responsibilities:
  • Primarily responsible for working collaboratively with Client’s practices to obtain missing referrals for specialty services prior to scheduled visits. Duties include running Ontrac worklist and checking information in the legacy systems to determine if a valid referral for the visit exists. If a valid referral is in the legacy systems incumbent will be responsible for linking to the referral number to the appropriate visit(s). For visits without a valid referral number in the legacy systems, incumbent will use the various payer technologies to obtain referral and authorization numbers for Client’s primary care practices. For specialty visits, contacting external PCPs to obtain referral numbers, coding the work in Ontrac and entering the information in the legacy systems.
  • Responsible for documenting and tracking the number of referrals that are generated and obtained. Also responsible for following-up with practices who do not immediately issue a referral, noting the reason for the delay. For referrals that are denied, documenting this information. Interfacing with practices and patients to report referral information. Complying with Patient Service Center productivity and customer service standards.
  • Responsible for verifying and updating patient registration information, including insurance, demographic and patient data in order to perform referral management function. Work collaboratively with the Registration Department to resolve registration issues. Responds to questions regarding open accounts or managed care/insurance issues.
  • Interfacing with patients will be necessary when information required to obtain an insurance referral is not complete. This includes, calling patient to obtain current PCP, insurance, visit information. Also responsible for communicating patient responsibility to contact payer via the Member Services Department or web-sites to update inaccurate information to maximize payment for visits. In addition, incumbent will be responsible for communicating benefit plan information to patients when necessary. Responsible for follow-up with patients to ensure that information has been updated with payers.
  • Works with all Client’s Support Staff and leadership to prioritize and facilitate referral processes to maintain integrity of service standards.
  • Develop a clear understanding of the various payor referral and authorization process and requirements for departmental policies and procedures.
  • Receives inquiries from customers, investigates and disseminates information to requestor and wider audiences as appropriate.
  • Works with Ontrac tool & reporting to review billing rejections to 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.
  • Identify need for escalation of issues or problems to appropriate supervisor or manager.
  • Performs other duties as assigned.
  • 1-3 years Healthcare experience
  • Bachelors degree or equivalent experience
  • Proficient in Office Software
  • Call Center environment experience
  • 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.
  • Computer Literate; knowledge of BICS, IDX, Percipio