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Job Location: Boston, MA
Req ID: 41362BR
Job Summary: Establishes and maintains effective procedures for managed care referrals for the department with commitment to providing the highest quality of service to patients in the ambulatory practice. Monitors outcomes to ensure insurance requirements are met. Provides referral management training and oversight to staff. Works closely with the Managed Care Office and BIDPO to communicate managed care principles and policies to the department.
Department Specific Job Responsibilities:
- Runs denial reports and follows up to ensure that denials are not due to issues related to obtaining authorization or referrals. Partners closely with billing and coding team on denials.
- Obtains self-pay / patient portion estimates for patients in partnership with OB/GYN billing team, Patient Financial Services, and other hospital departments.
- Ensures that Mass Health hysterectomy and sterilization forms are obtained in advance of surgery.
- Works with leadership to establish and maintain effective policies and procedures for managed care referrals, revenue cycle, and co-payment collection for the department. Ensures that all required managed care referrals for patient visits have been obtained or that a waiver is signed.
- Serves as primary resource on all departmental managed care matters; develops, implements and monitors departmental referral management processes, resource tools, and report findings on a regular basis.
- Represents the practice on hospital based Referral and Registration Operations committees. Acts as liaison between the practice and the managed care office and committees. Works closely with the physicians organization and the managed care office to communicate managed care principles and policies to the practice.
- Educates and trains administrative assistants and practice assistants in the area of Referral Management and Pre-Registration. Participates in administrative staff meetings reporting statistical referral management and pre-registration measurements and indicators, and communicating referral management information.
- Acts as a managed care resource on the unit to social workers, pharmacists, physicians, nurses and resource specialists for issues regarding managed care and insurance coverage, including commercial payers, Medicare, and radiology pre-certifications.
- High School diploma or GED required. Associate's degree preferred.
- 3-5 years related work experience required.
- Two years of experience in referral management or insurance managed care environment.
- Ability to travel occasionally to off-site location.
- Experience with computer systems required, including web based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint or Access.
- Decision Making: Ability to make decisions that are guided by general instructions and practices requiring some interpretation. May make recommendations for solving problems of moderate complexity and importance.
- Problem Solving: Ability to address problems that are varied, requiring analysis or interpretation of the situation using direct observation, knowledge and skills based on general precedents.
- Independence of Action: Ability to follow precedents and procedures. May set priorities and organize work within general guidelines. Seeks assistance when confronted with difficult and/or unpredictable situations. Work progress is monitored by supervisor/manager.
- Written Communications: Ability to communicate clearly and effectively in written English with internal and external customers.
- Oral Communications: Ability to comprehend and converse in English to communicate effectively with medical center staff, patients, families and external customers.
- Knowledge: Ability to demonstrate full working knowledge of standard concepts, practices, procedures and policies with the ability to use them in varied situations.
- Team Work: Ability to act as a team leader for small projects or work groups, creating a collaborative and respectful team environment and improving workflows. Results may impact the operations of one or more departments.
- Customer Service: Ability to provide a high level of customer service to patients, visitors, staff and external customers in a professional, service-oriented, respectful manner using skills in active listening and problem solving. Ability to remain calm in stressful situations.
Physical Nature of the Job:
Sedentary work: Exerting up to 10 pounds of force occasionally in carrying, lifting, pushing, pulling objects. Sitting most of the time, with walking and standing required only occasionally
EOE StatementBIDMC is EOE M/F/VET/DISABILITY/GENDER IDENTITY/SEXUAL ORIENTATION
VaccinesAs a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. BILH requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more about this requirement
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