Managed Care Services Rep
 Mass General Brigham (Enterprise Services) | |
 United States, Massachusetts, Somerville | |
| 399 Revolution Drive (Show on map) | |
 Mar 06, 2025 | |
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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.
This is a 100% work-from-home (remote) position. The schedule is Monday through Friday 8:30 AM-5PM EST 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:
Skills/Abilities:
Mass General Brigham Incorporated is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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. | |