Job Description

MANAGED CARE REPRESENTATIVE – PER DIEM

CLASSIFICATION/STATUS: Per diem (Full Time or Part Time)

IMMEDIATE SUPERVISOR: Managed Care Coordinator

SUPERVISORY RESPONSIBILITIES:  None

WHO YOU ARE: 

YOUR ROLE & IMPACT

As part of a dynamic team at Charles River Community Health (CRCH), a healthcare practice providing comprehensive and compassionate care to underserved communities, the MANAGED CARE REPRESENTATIVE (MCR) – PER DIEM will work collaboratively with primary care practices, specialty practices, referring physicians, primary care physicians, insurance carriers, patients, and other parties to ensure that required managed care referrals and prior authorizations for specified specialty visits and other services are obtained and appropriately recorded in the relevant practice management systems for patient appointments. The MANAGED CARE REPRESENTATIVE – PER DIEM will utilize available reports to follow-up on unresolved issues and denied claims.

The MANAGED CARE REPRESENTATIVE – PER DIEM will also manage logistics, including appointment arrangements, transportation, and translation services and will support the Coordinator in managing the electronic referral system. The MCR will also perform various administrative and clerical duties required to support these functions and may be required to perform other tasks as needed.

YOUR RESPONSIBILITIES

• Coordinate all outgoing/incoming referrals and prior authorizations.
• Schedule all referral appointments, including urgent requests, radiology exams, procedures and consultations.
• Verify insurance eligibility and submit insurance referrals and prior authorizations to ensure services are covered.
• Document appointment information on EHR, notify provider and patient with details, and mail out appointment letter.
• Prepare documentation, including office notes and labs, to fax to specialist office for upcoming appointment.
• Collaborate with the primary care provider to resolve issues related to specialist availability and patient needs.
• Process insurance referrals and prior authorizations received by fax and phone line from patients and hospitals.
• Scan and drop file insurance referrals in patients chart for easy access to authorization numbers, number of visits, and utilization.
• Maintain up-to-date knowledge of insurance company requirements and where patient’s insurance is accepted.
• Function as a resource for information and problem solving for patients, primary care providers, managed care program staff, specialists, and Health Center staff.
• Maintain and follows through closing the loop on all tracked referrals.
• Maintain HIPPA at all times.
• Understand the mission of the Health Center and strives to work collaboratively with Health Center staff to carry out this mission.
• Attend appropriate meetings to maintain up to date knowledge of Health Center activities and, if unable to attend meetings, follows up with supervisor for information.
• Attend appropriate various external organizational meetings with insurance companies and hospitals to remain up to date on any changes.
• Maintain documentation to meet audit requirements and participates in audit activities as requested.
• Performs other duties as assigned.

YOUR QUALIFICATIONS, COMPETENCIES, TRAITS

• High school diploma or GED required.
• Must have previous experience in health care setting.
• Must be detail-oriented with strong communication and organizational skills.
• Must have experience serving underrepresented communities similar to those we serve in Allston/Brighton and Waltham
• Familiarity with managed care plans preferred.
• Familiarity with EMRs and other healthcare software preferred.
• Team oriented, with a strong commitment to helping others.
• Bilingual in Spanish preferred.
• Must have familiarity with managed care plans and computer skills.
• Able to commute between sites Brighton/Waltham as needed.
• Able to answer high call volumes and attention to details with thorough follow-up.

WHO WE ARE & WHAT WE DO

CHARLES RIVER COMMUNITY HEALTH’S mission is to improve the health and well-being of the communities of Allston, Brighton, Waltham and surrounding areas by providing quality, compassionate, coordinated care that is patient-centered, family friendly, and community focused.

CRCH  is a comprehensive practice providing medical, pharmacy, dental, behavioral health, optical, and vision services to diverse underserved local communities.  We serve over 15,000 patients annually, and 80% of those served are well below the poverty line while over 60% speak in a language other than English.

We are committed to providing patients with timely access to the right care, at the right place and at the right time, collaborating with other organizations to connect patients with a comprehensive range of services and provide continuity of care, and creating new community partnerships to meet the changing needs of patients and the community.

We value caring for everyone with dignity, respect, and compassion, reducing cultural, financial and other barriers to care, and eliminating health care disparities for our patients. We also advocate for the needs of our patients, the community, and public health causes.

OUR PROMISE

If you are passionate about providing access to quality and compassionate care to the underserved, you will find your career rewarding and impactful.  As MANAGED CARE REPRESENTATIVE (MCR) - PER DIEM, you will be part of a dynamic team and will find a partner in your career path goals and trajectory!

OUR BENEFITS & PERKS

Medical & Dental Insurance

Short & Long-term Disability Insurance

Generous Paid Time Off

Flexible Spending Account

Employee Assistance Program

Tickets at Work

Health Reimbursement Arrangement

Travel Reimbursement

Professional Development Opportunities

Solid track record of developing and promoting employees internally!