Managed Care Representative I

Job Description

Job 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.
• Provide coverage for managed care co-workers during vacation, sickness, leave of absence, etc.

Candidate requirements :

High School Diploma is required; Associates Degree is preferred. Experience in a medial office environment and Medical Terminology are required. Must have strong computer experience. Minimum of one year of patient / public contact experience. Minimum of one year of Managed Care Insurance experience is preferred. Must have a strong sense of team commitment, which includes meeting deadlines, punctuality and excellent follow-through and feedback. Must display a high level of confidentiality, integrity, and initiative. Ability to form positive and collaborative relationships with peers and physicians at all levels within the company. Must possess exceptional interpersonal communication skills and can create a favorable impression for the organization to all staff, patients, and the public

Affirmative Action / EEO statement

Physicians East, P.A.is an equal opportunity employer and will not discriminate against any applicant or employee on the basis of age, race, color, ethnicity, religion, creed, sex (including gender, pregnancy, sexual orientation, and gender identity, which includes status as a transgender individual), national origin or ancestry, citizenship, past, current, or prospective service in the uniformed services, genetic information (including family medical history), physical or mental disability, or other legally protected status. Reasonable accommodation will be made for persons with disabilities during the application process and / or at the time of employment. Requests for accommodation should be made to the Human Resources Department as early as possible in the application / employment process. Contact HR Office at 252-413-6368 or email careers@physicianseast.com

Disclaimer

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.