Managed Care Coordinator - SouthPark Gastroenterology

Managed Care Coordinator - SouthPark Gastroenterology

The duties and responsibilities of this position include assisting patients and providers with coordinating of referrals, obtaining authorizations and scheduling. This position is also responsible for understanding benefits coverage and ensures the patient's care is coordinated. (This is a full time position that will support the Gastroenterology team at SouthPark, Monday to Friday 8 am to 5 pm)

Primary Job Responsibilities/Tasks may include, but not limited to:

• Obtains prior authorizations for surgical procedures, diagnostic imaging, and specialty services through commercial, Medicare and managed care insurance plans.
• Review provider orders and clinical documentation to ensure authorization requests meet payer requirements.
• Submit authorization requests via payer portals, fax, phone and electronic systems.
• Monitor authorization status and proactively follow-up with insurance companies to ensure timely determinations.
• Communicate with insurance representatives regarding authorization requirements, medical necessity criteria, and case updates.
• Process and review appointment confirmation, authorization approval, denial, and determination letters for accuracy.
• Notify providers, clinical staff, and patients of authorization outcomes and required next steps.
• Coordinate peer-to-peer review and appeals for denied authorization requests.
• Process outgoing referrals to specialist, facilities, and internal service providers.
• Maintain and attach accurate clinical documentation for all authorization types, and referrals within EMR system (Athena).
• Educate patients regarding authorization requirements, and referral status.
• Ensure authorizations are obtained prior to scheduled services to minimize delays and claim denials.
• Track authorization expiration dates, facility locations, and obtain extensions or renewals for diagnostic imaging as needed.

Requirements: Education, Experience and Certifications.

• High School Diploma or GED required.
• Thorough understanding of insurance coverage and Medical Necessity policies preferred.
• Customer service experience required.
• Knowledge of medical records software preferred.
• Completion of Hepatitis B Vaccine and Flu Vaccine Form will be required. Candidate may decline vaccination through declination form or may provide record of vaccination from previous employer.
• Completion of TB test will be required.

Physical Requirements.

• Work consistently requires walking, standing, sitting, lifting, reaching, stooping, bending, pushing, and pulling.
• Must be able to lift and support weight of 35 pounds
• Ability to concentrate on details.

Use of computer for long periods of time.