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Managed Care Coordinator

AmarilloAmerican Kennel Club


QUALIFICATIONS




Education: Must have as a minimum, a high school diploma or equivalency. Some college course work preferred.



Experience:Previous experience with prior authorizations and insurance verification is a must.



Knowledge, Skills, and Abilities:
  1. Excellent verbal and written communications skills are a must.
  2. Must have good mathematical skills and be able to calculate discounts and fees quickly.
  3. Previous experience in coordinating patient care in an alternate site setting is a must.
  4. Must be eligible for participation in all applicable State and Federal reimbursement programs. Cannot be excluded from participating in any of the programs.
  5. Must have the ability to work well under pressure and to diffuse potentially volatile situations.
  6. Must be self-motivated and be able to work without the absolute presence of a supervisor.
  7. Must posses an analytical or problem solving thought process.
  8. Must be confident, assertive, reliable, self-motivated, trustworthy, and sincere.

JOB SUMMARY:

Responsible for the coordination of patient benefits in regards to their alternate care services provided by the office. Obtains the initial authorization to provide services for the patient, verifies benefits, relays benefit information to the pharmacist staff and authorizes any new medications or services provided on existing patients. Re-authorizes patient services as needed based on the original authorization that was obtained.



ESSENTIAL FUNCTIONS (These duties must be performed with or without reasonable accommodation. This document in no way states or implies that these are the only duties to be performed by the employee occupying this position):


  1. Responsible for all case management duties for the IV Solutions patients including initial authorization, price negotiation, updates and extensions with insurance, Hospital case managers, employers, physicians and other sources required to coordinate the patient financial services.
  2. Works directly and indirectly with case managers, hospital discharge planners, physicians and other referral sources to coordinate clinically appropriate, cost effective services for patients.
  3. Responsible for evaluating guidelines to ensure the therapy is approved for the diagnosis.
  4. Acts as a resource for any and all subcontracted providers.
  5. Maintains a good working knowledge for all payor and provider contracts.
  6. Responsible for relaying important patient insurance and/or payor information to the pharmacist staff for future dispensing.
  7. Assists the VP of Operations with new contract preparation and presentation as necessary.
  8. Thoroughly reviews all the following for accuracy and up to date info before quoting any type of pricing to third party payors or case managers; compare current AWP through Amerisource Bergen with AWP in CPR+, compare contracted fee schedule with cost in CPR+ to ensure a positive gross margin.
  9. Secure needed medical documentation required or requested by third party insurance.
  10. Assist pharmacy staff with RX card rejections and submits for PA or cost overrides.
  11. Scans Insurance verification forms and other necessary documentation.
  12. Demonstrate knowledge of and supports policies and procedures, operating instructions, confidentiality standards, and the code of ethical behavior.
  13. Completes other miscellaneous duties as assigned.
  14. Maintains good inter/intra departmental relationships. Works to create an amiable atmosphere within the department and company.
  15. Responds to change, performance improvement support, professional growth, and meet development goals.
  16. Maintain regular attendance in accordance with established policies.
  17. Promptly report any allegations of impropriety to the Compliance Department.
  18. Comply with Maxor’s Ethical Business Conduct policy and Maxor’s Compliance Program.
  19. Remain free from exclusion under the OIG and SAMS Medicare/Medicaid lists.
  20. Complete required training, as assigned, within the established timeframes.
  21. Must be able to cope with the mental and emotional stress of the position.










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