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Our Integrated Network brings together a diversity of experienced private practice and employed physicians as well as community and academic providers. While we are one unified network, we focus on different geographic regions, with local care teams convening to ensure healthy, happy neighborhoods throughout the greater Boston region.

Job Profile Summary

​This role focuses on performing activities associated with evaluating, developing, recommending, implementing, and carrying out the policies and procedures related to the delivery of high quality patient care. In addition, this role focuses on performing the following Care Navigation related duties include: Focuses on the patient's needs and helps guide the patient through the healthcare system and works to overcome obstacles that are in the way of the patient receiving the care and treatment they require. An organizational related support or service (administrative or clerical) role or a role that focuses on support of daily business activities (e.g., technical, clinical, non-clinical) operating in a “hands on” environment. The majority of time is spent in the delivery of support services or activities, typically under supervision. An experienced level role that requires basic knowledge of job procedures and tools obtained through work experience and may require vocational or technical education. Works under moderate supervision, problems are typically of a routine nature, but may at times require interpretation or deviation from standard procedures, and communicates information that requires some explanation or interpretation.

Role is remote but may require occasional onsite meetings

Job Overview

This position triages incoming requests from patients and primary care providers for managed care referrals for patients who have selected primary care physicians (PCPs) in healthcare system. The primary purpose of this position is to minimizing the leakage rate to out-of-network providers. This position will demonstrate outstanding customer service and interpersonal communication with a drive to exceed customer’s service expectations.

Job Description

Minimum Qualifications:

1. High school diploma or equivalent

2. One (1) year of experience in insurance, billing, patient access in health care.

Preferred Qualifications:

1. Two (2) years of experience in insurance, billing, patient access in health care.

2. Bilingual.

Duties and Responsibilities : The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

1. Processes all requests for referrals, specialist treatments and procedures, durable medical equipment, therapies, etc., according to the requirements specified by the various insurance carriers.

2. Triages requests according to department guidelines, ensuring referrals stay within network unless meeting specific exceptional criteria; ensure a turn-around time of 3-5 business days to complete requests.

3. Verifies eligibility of insurance coverage via the NEHEN system or directly via the payer websites.

4. Utilizes Physician Access Line staff to provide expedited appointment service for referrals staying in-network.

5. Involves Manager as needed based on departmental Referral Guidelines.

6. Maintains referral data entry for General Medical Associates in the Logician Referral Management module; messages staff and/or PCPs/NPs as needed for assistance in understanding and then processing the requests.

7. Maintains log of Community PCP referral requests for out of network care; provides monthly statistical reports to Manager.

8. Follows up with patients on all requests for referrals to ensure patients have made/kept appointments; assist with scheduling/rescheduling those patients who have not yet been seen as directed.

9. Ensures that specialist communication has been received; follow up to obtain notes from those who have not sent notes to the PCP.

10. Maintains knowledge of the requirements governing release of patient health information (PHI) including HIPAA, HIV, Mental Health, and substance abuse cases.

11. Maintains current in-depth knowledge on all insurances that require referrals and follows their referral management protocol.

12. Maintains collaborative, team relationships with peers and colleagues in order to effectively contribute to the achievement of goals, and to help foster a positive work environment.

Physical Requirements:

1. Frequent sitting, occasional standing or working, and lifting of 10-15 points.

2. May be exposed to dust and other typical office-like discomforts.

3. Manual dexterity using fine hand manipulations for computer keyboard operation.

4. Requires ability to see computer screen and read reports.

5. Requires ability to hear instructions from physicians and other clinical or nursing staff.

Skills & Abilities:

1. Computer literacy required including familiarity with word processing programs and electronic spreadsheets and facility in learning new applications.

2. Excellent customer service skills including excellent interpersonal and telephone skills.

3. High degree of tact is necessary due to frequent interaction with patients, physicians, and insurance companies.

4. Strong business skills, including understanding of health care expense, revenue, and reimbursement models and how they affect business plans.

5. Ability to develop recommendations based on analysis and lead teams and drive to decisions.

6. Excellent organizational skills required with attention to detail. Ability to prioritize work and be flexible with work assignments.

Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine. Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation by emailing us at careers@tuftsmedicine.org .