Managed Care Coordinator - SouthPark Gastroenterology

Primary Job Responsibilities/Tasks

• 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.
• Cookordinate 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

• 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.
• Able to concentrate on details.