Managed Care Coordinator

JOB SUMMARY

The Managed Care Coordinator is responsible for completing insurance requirements and providing case management support for services delivered across various patient care settings. This individual obtains and communicates insurance benefit information to patients and internal departments, ensuring accurate and timely coordination of coverage. The Managed Care Coordinator supports both patients and providers by identifying alternative solutions for non-covered services, collaborating closely with providers, insurance carriers, and Patient Assistance Counselors. Additionally, this role contributes to the effectiveness of care delivery by facilitating access to resources, supporting financial navigation, and aligning activities with organizational policies and patient care goals.

ESSENTIAL JOB FUNCTIONS

1. Completes managed care insurance requirements for services ordered or provided by health system providers, ensuring adherence to policy and payer guidelines.
2. Monitor services requiring case management by reviewing medical/dental records, patient appointments, and communicating with patients, providers, and insurance companies to verify coverage compliance.
3. Contact patients to obtain insurance information, communicate cost estimates, and relay other care-related details necessary to fulfill managed care requirements.
4. Reviews appointment schedules to verify and update patient insurance eligibility for each visit.
5. Reviews patient accounts for Patient Responsibility balances and provides patient counseling regarding expected payments including pre-pay and non-covered services.
6. Works with providers and patient care teams to obtain, submit, manage and verify prior authorizations.
7. Documents all patient interactions and actions taken, maintaining accurate records for future reference.
8. Communicates insurance coverage limitations and requirements to patients and care teams to ensure clear understanding and proper coordination of services across the health system.
9. Assist patients, staff, and external providers with appeals, retrospective referrals, prior authorizations, and denied claims to maximize reimbursement and deliver high-quality customer service.
10. Supports coordination, training, and education related to prior authorization and managed care requirements for patients, providers, and staff to optimize reimbursement processes.
11. Refers underinsured or uninsured patients to Patient Assistance Counselors and coordinates point-of-service pre-payment processes when applicable to mitigate organizational bad debt.
12. Maintains strict adherence to scheduled work hours with regular and reliable attendance.
13. Performs other duties as assigned.

EDUCATION AND EXPERIENCE

1. High school diploma or equivalent.
2. Minimum of two years' experience in a medical/dental business office or healthcare setting; understanding of insurance eligibility and benefit verification.
3. Graduation from a Medical Assistant, Health Unit Coordinator, or Health Care Business Services program preferred.

CERTIFICATIONS / LICENSES

Valid Wisconsin Driver's License required with an acceptable motor vehicle record (MVR), per FHC guidelines.

Equal Opportunity Employer