Insurance Program Coordinator II
GENERAL SUMMARY OF POSITION:
Under the general direction of the Manager or designee, the Insurance Program Coordinator II is assigned to a specific hospital or program. This position will be responsible for traveling to alternate work stations at the hospital sites and working with hospital or program staff to obtain, investigate and manage cases. The Insurance Program Coordinator will seek to maximize benefits available in private and public programs in order to preserve MassHealth as payor of the last resort.
The Enhanced Coordination of Benefits Unit is responsible for coordinating insurance benefits for high cost, medically complex MassHealth or pending MassHealth members who have access to commercial health insurance. The goal of the program is to ensure that MassHealth is the payor of last resort.Responsibilities
- Consult with Patient Financial Counselors, Social Workers and Case Managers at hospitals to investigate referrals based on the patient’s current and prospective medical needs.
- Identify, evaluate, and coordinate health care benefits including rehabilitative and pharmacy services with Commercial Insurers for referrals received both internally and externally.
- Review family/social dynamics of the MassHealth member and investigate to determine availability or access to commercial health insurance, Premium Assistance and other State and Federal programs for which they may qualify.
- Educate members and families on commercial health insurance coverage based on their summary plan descriptions and explain how their MassHealth benefits work in conjunction with private health insurance.
- Analyze clinical, demographic and claims data to identify current and potential high utilizers of healthcare.
- Ensure that services provided maximize all payment sources that are available to the member while maintaining MassHealth as the payor of last resort.
- Interact with Mass Health members, providers, families, MassHealth staff, Center staff and insurers to manage health care benefits as they relates to the member’s plan of care.
- Document and track all information associated with a case and report MassHealth cost savings and provider revenue enhancement based on service costs deferred to other Insurers.
- Provide ongoing education to health care providers relating to MassHealth and Commercial Insurance regulations.
- Make appropriate referrals to various MassHealth units such as TPL Identification, MassHealth Standard and CommonHealth Premium Assistance, Disability Evaluation Services, and Community Case Management, and coordinate functions as required.
- Assist MassHealth member in accessing all available public programs for which they may qualify.
- Perform all other duties as assigned.
- Bachelor’s degree in Health Care Administration or equivalent Case Management or Insurance Coordination experience.
- 5 years relevant experience in a health care setting or legal setting.
- Expert knowledge of the insurance market and insurance coverage issues.
- Expert knowledge of complex medical needs.
- Working knowledge of rules and regulations of the Medicare, Commercial Insurance and Mass Health programs.
- Strong oral written communication skills.
- Effective Negotiating skills.
- Proficient in Word, Windows, Excel, Power Point, and FoxPro.
- Ability to travel in state as required
- Case Management, Discharge Planning or Case Management certification a plus.