HMO and Medicaid Coordinator

HMO & Medicaid Coordinator

Position Summary

The HMO & Medicaid Coordinator is responsible for coordinating managed care (HMO) authorization processes and assisting residents and families with Medicaid eligibility and application procedures. This position supports the interdisciplinary team by ensuring timely payer communication, maintaining accurate documentation and tracking systems, assisting with utilization review activities, and facilitating Medicaid application approval while maintaining compliance with all applicable federal, state, and facility regulations.

Delegation of Authority

As the HMO & Medicaid Coordinator, you are delegated the administrative authority, responsibility, and accountability necessary to perform the duties of this position under the direction of the MDS Director, Business Office Manager, or other designated supervisor.

Essential Duties and Responsibilities

HMO Coordination

• Coordinate the HMO authorization and managed care process under the direction of the MDS Director or designee.
• Maintain HMO tracking logs, spreadsheets, and weekly calendars to ensure timely submission of clinical updates and progress reports.
• Assist with submitting beneficiary notices to residents and families as directed.
• Assist with audits, Additional Documentation Requests (ADRs), and data collection under the supervision of the MDS Director or designee.
• Perform daily census and payer reconciliation between facility systems (including PCC EMR and other applicable systems).
• Participate in Utilization Review meetings and collaborate with the interdisciplinary team regarding managed care cases.
• Communicate with insurance representatives and managed care organizations regarding authorizations, continued stay reviews, and reimbursement requirements.
• Maintain accurate documentation of payer communications and authorization status.

Medicaid Coordination

• Screen, interview, and assess residents to determine Medicaid eligibility.
• Receive, review, and process admission referrals for residents requiring Medicaid assistance.
• Educate residents and responsible parties regarding Medicaid eligibility requirements and application procedures.
• Collect, organize, and verify all required documentation needed to complete Medicaid applications.
• Submit Medicaid applications and supporting documentation electronically through appropriate state systems.
• Correspond with Human Resources Administration (HRA), Medicaid caseworkers, and other agencies regarding application status and outstanding documentation.
• Monitor pending applications and follow up to ensure timely approvals and eligibility determinations.
• Obtain financial information and supporting documentation necessary to determine eligibility for Medicaid and other financial assistance programs.
• Maintain accurate records of all Medicaid applications, renewals, and case activity.
• Assist residents and families with Medicaid recertifications and ongoing eligibility requirements as needed.

Administrative Responsibilities:

• Maintain confidentiality of resident information in accordance with HIPAA regulations.
• Ensure all documentation is complete, accurate, and maintained according to facility policies and regulatory requirements.
• Collaborate with Admissions, Social Services, Nursing, MDS, Business Office, and other departments to ensure seamless coordination of resident financial and payer needs.
• Prepare reports and maintain tracking systems related to HMO authorizations and Medicaid applications.
• Stay current on changes to Medicaid regulations, managed care policies, and reimbursement guidelines.
• Perform other related duties as assigned by the MDS Director, Business Office Manager, or Administrator.

Qualifications

Required:

• High school diploma or equivalent.
• Strong organizational, communication, and customer service skills.
• Proficiency with Microsoft Office applications and electronic medical record (EMR) systems.
• Ability to manage multiple priorities while meeting deadlines.
• Knowledge of HIPAA privacy and confidentiality requirements.

Preferred:

• Bachelor’s degree in Business Administration, Healthcare Administration, Accounting, Finance, Social Work, or a related field.
• Previous experience with Medicaid eligibility, managed care authorizations, insurance verification, or reimbursement in a skilled nursing, rehabilitation, or healthcare setting.
• Experience using PCC or other electronic medical record systems.
• Knowledge of Medicaid regulations and managed care reimbursement processes.

Knowledge, Skills, and Abilities:

• Excellent organizational and time management skills.
• Strong attention to detail and accuracy.
• Effective verbal and written communication skills.
• Ability to work independently while collaborating with an interdisciplinary team.
• Ability to maintain professionalism and confidentiality when handling sensitive financial and medical information.
• Strong problem-solving and follow-up skills.
• Ability to build positive relationships with residents, families, insurance representatives, and government agencies.

Physical Requirements

• Ability to sit, stand, walk, bend, and reach throughout the workday.
• Ability to operate standard office equipment, including computers, telephones, scanners, and copiers.
• Ability to lift and carry up to 20 pounds occasionally.
• Ability to perform repetitive hand and finger movements for computer use.

Work Environment

This position is performed in a skilled nursing and rehabilitation facility and involves frequent interaction with residents, families, healthcare professionals, insurance representatives, and government agencies. The HMO & Medicaid Coordinator is expected to maintain professionalism, confidentiality, and a resident-centered approach while supporting the facility's financial and clinical operations.