Managed Care Service Rep

Referral Services Representative

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 :

• The Patient Service Center is a centralized call center. Incumbents receive calls, place calls and obtain / generate insurance referrals.
• 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.
• 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.
• Responsible for verifying and updating patient registration information, including insurance, demographic and patient data needed to perform referral management functions.
• Interfacing with patients will be necessary when information required to obtain an insurance referral cannot be completed.
• 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.
• Works with all Mass General Brigham Support Staff and leadership to prioritize and facilitate referral processes to maintain integrity of service standards.
• Develops a clear understanding of the various payor referral and authorization process and requirements for departmental policies and procedures.
• 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.
• Receives inquiries from customers, investigates and disseminates information to requestor and wider audiences as appropriate.
• Works EPIC work queues to review billing rejections and resolve insurance issues to maximize reimbursement.
• Identifies need for escalation of issues or problems to appropriate supervisor or manager.
• Performs other duties as assigned.

Qualifications :

Skills / Abilities :

Additional Job Details (if applicable) :