Managed Care Services Rep
Spaulding Rehabilitation
Site: Mass General Brigham Incorporated
Principal Duties and Responsibilities:
1. The Patient Service Center is a centralized call center. Incumbents receive calls, place calls and obtain/generate insurance referrals.
2. Primarily 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, follow-up 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. Follow-up requires entering information into EPIC.
3. Responsible for documenting and tracking the number of referrals that are deferred, generated and obtained. Following-up 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.
4. Responsible 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.
5. Interfacing 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) re-verify insurance information with the patient, correcting information in Mass General Brigham’ systems and then resubmitting referral requests to the insurance company.
6. Responsible for communicating benefit plan information to patients when necessary and following-up with insurance companies and/or patients to ensure information has been updated with payers.
7. Works with all Mass General Brigham Support Staff and leadership to prioritize and facilitate referral processes to maintain integrity of service standards.
8. Develops a clear understanding of the various payor referral and authorization process and requirements for departmental policies and procedures.
9. Serves 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.
10. Receives inquiries from customers, investigates and disseminates information to requestor and wider audiences as appropriate.
11. Works 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.
12. Identifies need for escalation of issues or problems to appropriate supervisor or manager.
13. Performs other duties as assigned.
Ability to communicate and interact effectively with all levels of hospital personnelAbility to maintain confidentiality with regard to all phases of the workAbility to withstand the pressure of continual deadlines and receipt of work with variable requirementsAbility to concentrate and maintain accuracy in spite of frequent interruptionsAbility to be courteous, tactful, and cooperative throughout the working dayAbility to use judgment in carrying out all phases of the workAbility to use standard office equipment including computers, photocopy and facsimile machines, and readers/printersExcellent Customer Service Skills, demonstrated ability to use appropriate judgment, independent thinking and creativity when resolving customer issues.
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 not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing 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
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 Epic’s 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 follow-up 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 as-needed basis, may be required to perform other tasks.Principal Duties and Responsibilities:
1. The Patient Service Center is a centralized call center. Incumbents receive calls, place calls and obtain/generate insurance referrals.
2. Primarily 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, follow-up 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. Follow-up requires entering information into EPIC.
3. Responsible for documenting and tracking the number of referrals that are deferred, generated and obtained. Following-up 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.
4. Responsible 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.
5. Interfacing 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) re-verify insurance information with the patient, correcting information in Mass General Brigham’ systems and then resubmitting referral requests to the insurance company.
6. Responsible for communicating benefit plan information to patients when necessary and following-up with insurance companies and/or patients to ensure information has been updated with payers.
7. Works with all Mass General Brigham Support Staff and leadership to prioritize and facilitate referral processes to maintain integrity of service standards.
8. Develops a clear understanding of the various payor referral and authorization process and requirements for departmental policies and procedures.
9. Serves 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.
10. Receives inquiries from customers, investigates and disseminates information to requestor and wider audiences as appropriate.
11. Works 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.
12. Identifies need for escalation of issues or problems to appropriate supervisor or manager.
13. Performs other duties as assigned.
Qualifications
Qualifications: High school diploma or equivalent required. Associate or Bachelor’s Degree preferred.Minimum of 3 years of Registration, Scheduling and Insurance Authorization experience within a healthcare setting is requiredAn effective team player with strong inter-personal skillsDemonstrated ability to work and make decisions in a fast paced, high volume work environmentProficient with office software packages such as word processing and spreadsheets, including Epic and any other system the PSC may be utilizingCall Center environment experience5 years of customer service experience is requiredExperience with EPIC and medical office workflows requiredProficient computer skills; Experience with Microsoft Office applications (Outlook, Word and Excel)
Additional Job Details (if applicable)
Skills/Abilities:
The ability to set prioritize and follow through with responsibilitiesAbility to exercise appropriate judgment with sensitive and confidential materialThe ability to successfully resolve conflictAbility to communicate and interact effectively with all levels of hospital personnelAbility to maintain confidentiality with regard to all phases of the workAbility to withstand the pressure of continual deadlines and receipt of work with variable requirementsAbility to concentrate and maintain accuracy in spite of frequent interruptionsAbility to be courteous, tactful, and cooperative throughout the working dayAbility to use judgment in carrying out all phases of the workAbility to use standard office equipment including computers, photocopy and facsimile machines, and readers/printersExcellent Customer Service Skills, demonstrated ability to use appropriate judgment, independent thinking and creativity when resolving customer issues.
Remote Type
Remote
Work Location
399 Revolution Drive
Scheduled Weekly Hours
40
Employee Type
Regular
Work Shift
Day (United States of America)
Pay Range
$19.42 - $27.74/Hourly
Grade
3
EEO Statement:
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 Veteran’s 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)-282-7642.
At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.
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