Managed Care Coordinator Resume Samples

Description :

1. Responsible for the resolution of Medicaid health plan issues with both providers and clients.
2. Referenced the state and federal rules and regulations pertaining to health plan enrollment.
3. Responsible for investigating complaints and addressing provider billing issues.
4. Identified eligibility policy and issues that effects both HMO Enrollment and Medicaid and clarify and resolves complex client enrollment issues that fall out of the normal scope of our enrollment contractors.
5. Managed Care Organizations such as Health Maintenance organizations (HMO's) and the counties, Xerox, and serves as a resource for others regarding Managed Care Organization.
6. Analyzed eligibility rules and makes judgments in tailoring the existing standards so they can be applied to a particular circumstance and to deal with emergencies.
7. Communicated about general program and client issues, relevant to all MA and policies and other information relevant to determining MCO enrollments/disenrollment's, while being cognizant of the impact the policies will have on the program.

Experience

7-10 Years

Level

Management

Education

Medical Billing Home Care

Description :

1. Assisted one or more groups of physicians, advanced care practitioners, providers and clinical and non-clinical staff.
2. Ensured competent and accurate appointment scheduling while maintaining the efficient flow of all incoming calls.
3. Provided appropriate screening, handling and routing of all incoming phone calls and ensures patient messages are taken appropriately with pertinent information.
4. Processed physician and outpatient referrals.
5. Responsible for patient scheduling, obtaining insurance authorization, providing appropriate guidance regarding coverage and closing the loop within the EHR and inter facing with other payer portals for processing referrals.
6. Entered accurate patient data into EHR, validates information, obtains necessary verifications and pre-authorizations on all new patient appointments.
7. Prioritized the urgency of patient referrals; including stats, urgent or routine.

Experience

7-10 Years

Level

Senior

Education

Spanish

Description :

1. Coordinated all insurance needs for patients that needed referrals to specialists and freestanding facilities by our six internal medical doctors.
2. Referrals generated for each patient using an online system called Medconnect.
3. Contacted the insurance companies and submitted clinical information for surgical authorizations, prescription refills and other types of recommended care by the physician.
4. Assisted opening the office in the morning and frequently helped in other departments such as medical records, switchboard, and cashiering.
5. Coordinated contact between drug reps and doctors in the facility Responsibility of split coding Medicare patient's annual preventative health screenings.
6. Working knowledge of organization policies and procedures with the ability to read, interpret and apply clinic policies and procedures.
7. Contacted the insurance companies and submitted clinical information for surgical authorizations, prescription refills and other types of recommended care by the physician.

Experience

2-5 Years

Level

Junior

Education

Certificate

Description :

1. Provided Case Managers with concurrent reviews.
2. Drafted one-time payment agreement between VITAS Healthcare and other Non-par payors Reviewed clinical documentation to ensure it meets the standard of medical necessity.
3. Communicated with insurance companies to ensure proper and timely authorizations.
4. Ensured that patient's level of care is appropriate as to terms of contracts.
5. Demonstrated a working knowledge of hospice, Medicaid, and Medicare regulations.
6. Possessed a working knowledge of Florida HMO (Health Maintenance Organization) Statute.
7. Ensured that the company operated within the ambit of the Law during business transactions.
8. Successfully negotiated rates with non-contracted insurance payors.
9. Delivered effective customer service through telephonic Case Management.

Experience

10+ Years

Level

Senior

Education

Masters Of Accounting

Description :

1. Managed Care contracting (for physician billing) and claims payment process by analyzing, resolving problems related to plan linkage on behalf of salaried providers rendering clinic outpatient, inpatient, and faculty practice physician services.
2. Managed delegated credentialing process and direct submission of demographic data and credentials.
3. Built effective relationships with Payer Network Management and Managed Care Department to insure faculty and clinic provider activities are given priority processing and claims settlement according to contract.
4. Worked in collaboration with the Medical Staff Office maintaining provider credentialing database, primary source verification, NCQA, CMS and JCAHO standards are met in preparation for MCO audits.
5. Provided Administrative Directors plan participation status and ID# for distribution to site managers to facilitate the referral and authorization process; billing to initiate claims process.
6. Identified data disparities between group contracted plan sources and Managed Care database on ongoing basis to limit negative impact on revenue, pre-certs and referrals.
7. Identified root causes.

Experience

10+ Years

Level

Senior

Education

B.S. In Marketing

Description :

1. Managed Care Coordinator for 10 General Surgeons ,1 Plastic Surgeon and 1 Urologist at Centegra Surgical Associates.
2. Responsible for knowing referrals and pre-certification requirements for each contracted Insurance Company.
3. Acted as a liaison between the insurance companies, physicians and clinical staff.
4. Responsible for initiation of referrals and pre-certification for radiology procedures, test and surgeries ordered by CPC physicians.
5. Identified criteria for pre-authorizing procedures with insurance companies.
6. Assisted in gathering information for referrals and processing paperwork.
7. Responsible to provide managed care insurance education for patients and staff.
8. Interfaced with staff to insure that patient's managed care Insurance needs are met.
9. Responsible for utilizing appropriate ICD-9 and CPT codes.

Experience

2-5 Years

Level

Executive

Education

High School Diploma

Description :

1. Coordinated with on & off site insurance reviewers daily, maintain relationships and communicate daily with health plans, IPA's, medical groups & physicians to ensure authorizations are in place during admission and final authorization upon discharge.
2. Organized and maintained insurance liaisons access to eTenet portal & Cerner EMAR system.
3. Assisted with in-house denial recovery; collaborate with Business Office, medical groups, physicians and case management for short and long term planning.
4. Reviewed, tracked denials and disputes through analysis of reports to determine the root cause and facilitate resolution in conjunction with DCM oversight.
5. Generated reports and projects to improve hospital & department metrics.
6. Monitored each units concurrent reviews and collaborate with RN/Case Manager to ensure reviews are sent timely and to the correct payer to ensure authorization & financial clearance.
7. Provided leadership to case management team.
8. Trained & mentored new hires about managed care entities.

Experience

10+ Years

Level

Senior

Education

Masters Of Science

Description :

1. Issued referrals for Outpatient consultations, testing, and procedures for patients of Union Medical Center.
2. Scheduled urgent appointments for patients requested by Primary Care Physicians at Union Medical Center.
3. Explained instructions for Colonoscopy and Lower GI preps and various tests for patients before scheduling.
4. Verified eligibility and referrals for contracted facilities.
5. Authorized medication prescribed by either contracted facilities/doctors or Emergency Room visits.
6. Assisted patients with Durable Medical Equipment.
7. Responsible for maintaining specific caseload of patients/clients with physical and/or mental disabilities coordinating all aspects of patient care by scheduling of doctor appointments, physical therapy/speech therapy, inpatient or outpatient testing as prescribed by physician, lab work or any health related issue for our client.

Experience

10+ Years

Level

Senior

Education

High School Diploma

Description :

1. Entered new patients into the system.
2. Reviewed insurance issues and update insurance in system.
3. Welcomed patients when they arrived and set up additional appointment when leaving.
4. Helped to set up and operate the first case management department for the 24 county home health care, durable medical .
5. Assumed the lead role in coordinating healthcare services for ailing Father.
6. Developed and instituted processes and systems to track wellness.
7. Defined and implemented strategic direction, client relationships and service agreements for a community of members and providers under managed care options.
8. Worked alongside social workers and nurses in order to service those under the health plan with the benefits in which they are authorized to receive by communicating with contracted.

Experience

7-10 Years

Level

Management

Education

High School Diploma

Description :

1. Created, developed, and updated multi-use managed care contract matrixes.
2. Completed and reviewed managed care applications, and facilitated credentialing/recredentialing process.
3. Conducted preliminary review of managed care contracts and analyzed key contract issues on which to base recommendations to physicians.
4. Prepared and analyzed revenue reports in order to assess managed care organizations performance upon renewal.
5. Created system in which to verify benefits for scheduled patients prior to office visits.
6. Developed and presented to Baylor System Support Committee financial codes to assist in tracking managed care patients.
7. Reviewed/advised on any discrepancies, managed care payments and/or allowables.
8. Responsible for trouble-shooting any managed care issues.

Experience

5-7 Years

Level

Executive

Education

General Business