Providence Medical Management Coordinator in Portland, Oregon
Providence is calling a Medical Management Coordinator - Pmg Referral Operations (1.0 FTE, Days) to Providence Office Park Portland, OR. Anticipated work schedule will be between 7:00am to 5:30pm Monday-Friday
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We are seeking a Medical Management Coordinator - Pmg Referral Operations who will be responsible for the implementation of policies and procedures relating to aspects of the Medical Management Program and Work plan of Providence Physicians Division (PPD) and performs duties supporting the core functional areas of: specialist referral processing, prior authorization, diagnostic imaging scheduling, physician call triaging, appeals, auditing and training. The work focuses on the technical support and the organization/coordination of support activities such as: production, program outcomes against stated policies, standards and objectives; and the development of training and documentation for process and performance improvement activities relevant to the Medical Management Program. The Medical Management Coordinator assures an integrated approach to the program is fulfilled, resulting in timely scheduling of requested services, communication across the continuum of care for requested outpatient services resulting in improvement in the provision of care and services and improved satisfaction for our patients, providers, staff and external contacts. The Medical Management Coordinator functions in a team environment, providing requested services in a centralized setting on behalf of the PPD clinics.
This position serves as an expert resource to PPD providers, specialists and staff in regard to the specialist referral / prior authorization requirements for multiple contracted and non-contracted insurance plans, diagnostic imaging protocols which vary between the multiple facilities/sites providing this service, and processes relating to these functions.
This position is the liaison between PPD physicians, patients, multiple Providence Health System Diagnostic Imaging scheduling and modality (e.g., CT, MRI, Nuclear Medicine) departments, freestanding diagnostic imaging centers and the contracted insurance plans. In addition to specialist referral processing, this position also facilitates prior-authorization for selected procedures as directed by the patients' insurance.
In this position you will have the following responsibilities:
Proficient in the principle duties or functions of one or more core Medical Management functional areas, Referrals, Prior Authorizations, Diagnostic Imaging Scheduling, Appeals, Audit/Training
Coordinate the referral management and diagnostic imaging scheduling processes for PPD patients in a centralized department setting, includes responding to provider and facility calls, determining and relaying benefit information as it relates to referral processing or diagnostic imaging authorization or scheduling and oversees daily activities to ensure completion within specified timeframes
Act as a resource and lead contact for the PPD Medical Management Program and provides technical assistance to the clinical staff and/or medical directors on patient's coverage, authorization guidelines and procedures, diagnostic imaging protocols, coding systems, claims research, contracted specialist network and department operating procedures
Use scheduling systems and understands differing protocols for diagnostic imaging services at multiple Providence Health System facilities and freestanding diagnostic imaging centers within specified timeframes
Clearly communicates and confirms patient understanding of preparation requirements relevant to specific facility to patients when scheduling diagnostic imaging exams
Receive and appropriately triages phone calls from Providence hospital-based physicians (e.g., Emergency Department or Hospitalist physician) who must speak with a patient's personal physician on an urgent basis
Train or re-train staff as necessary based on expertise, experience, action plans, external changes or functions
Work with peers and others to resolve service or production problems. Serve as a liaison and resource to the patient, clinic staff and the patient's insurance plan for problem resolution purposes in regard to referrals, authorizations and diagnostic imaging scheduling services.
Develop or revise, or assist to develop or revise written documentation for referral processing, and diagnostic imaging scheduling including department or unit policies, procedures, work flows, current diagnostic imaging protocols for each Providence Health System facility, internal phone lists, external contact list for preferred provider offices and insurance plans and contracted specialist and facility updates
Process all paperwork/forms related to referral processing and diagnostic imaging scheduling, including electronic distribution (fax, web-site applications, and/or telephone) to insurance companies and specialist offices to ensure appropriate turn around time. This may include providing back up for other PPD Medical Management Coordinators
Verify member eligibility as required to process referral and/or authorizations, works with office staff to update insurance information if current patient registration information is inaccurate
Assist providers with appropriate CPT and/or ICD-9 diagnosis coding as needed to comply with insurance coverage guidelines
For delegated plans, review patient chart to obtain documentation supporting medical necessity of requested services. Insert relevant clinical information on referral form and includes benefit information (i.e., Line-Finder, stated Limitations/Exclusions for patient's plan) pertinent to medical review process.
Contact specialist office to obtain clinical information (chart notes, diagnostic results) as needed to assist in medical review process
Participate on or lead process improvement work teams according to expertise within PPD or Providence Health System and may provide back up for other PPD administrative staff (Diagnostic Imaging Scheduling, Quality Management, Clinical Research), as needed
Required qualifications for this position includes:
High School Diploma -OR- GED
Current state registration, license, or certification as appropriate to education
Preferred qualifications for this position includes:
Bachelor's Degree -OR- Work experience in a medical clinic or managed care/health insurance plan (3) years in a related field
Three (3) years Experience in a utilization management functional area such as prior authorization, medical audit, appeals or delegation
Two (2) years Additional years in a business environment
Certified Medical Assistant (CMA) or Medical Assistant (MA) with clinical experience working in clinic setting
Logician and Pathways® software experience.
Experience in database management and spreadsheets
Working knowledge in a utilization management functional area such as prior authorization, medical audit, appeals or delegation
Proficiency in data processing skills, such as word processing and email. Knowledge of database management and spreadsheets
About Providence in Oregon
As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.
The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple,
"Providence will provide the best care and service to every person, every time."
Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.
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As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Administrative (Clinical)
Req ID: 297363
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