Referral Management Clerk (CLR/RMC/Appointment Line Technician) - JB Charleston, SC

Referral Management Clerk (CLR/RMC/Appointment Line Technician) Charleston AFB, SC

Reef Systems has an immediate need for a Referral Management Clerk to support the Air Force Medical Service (AFMS) mission at the Referral Management Center (RMC) located at Charleston AFB, South Carolina. This is a full-time, on-site position.

The Air Force Medical Service (AFMS) operates and manages a worldwide healthcare system to deliver medical service for more than 2.63 million eligible beneficiaries. Beneficiaries include active duty, family members and retirees, during both peacetime and wartime. The AFMS responds to a full spectrum of anticipated health requirements and provides an integrated healthcare system from forward deployed locations through definitive care with an emphasis on prevention of illness and injury.

Each referral is coordinated through a process called Referral Management (RM). When specialty care is referred, the Referral Management Center (RMC) is responsible for advising the patient of their benefit and working with the referring provider and the Managed Care Support Contractor (MCSC) to ensure that the referral is accurate. The RMC is also responsible for coordinating the referral with the specialty office, facilitating the recapture of Medical Treatment Facility (MTF) direct care capabilities, tracking the referral to closure, and returning all results of treatment to the patient's medical record.

The number of referrals in a MTF varies depending on the patient population, illness severity, local networks, and referral patterns.

The Contractor shall support the AFMS' mission of staffing and managing RMCs at the MTFs, serving as the one-stop shop for all referrals from the initiation of a referral to receipt of a clear, legible, Health Insurance Portability and Accountability Act (HIPAA) (Appendix D) compliant report is returned to the MTF. The RMC serves as the central clearing house for providers and patients needing information or help with referrals. RM is a critical program within DoD and the AFMS, supporting the patient-centered medical home model and optimizing the MTF's clinical specialty capabilities and expeditionary medicine currency platforms.

Referral Management Center (RMC) Operations:

• Operate the RMC at the MTFs listed within Appendix A. Support RMC operations and provide referral management services to patients during normal MTF business hours (as specified in paragraph 4) for telephonic, electronic, and in person access.
• Process and review referrals in Government information systems including, but not limited to: MHS GENESIS, the Composite Health Care Suite (CHCS), MCSC referral systems, Armed Forces Health Longitudinal Technology Application (AHLTA), Health Artifact Imaging & Management System (HAIMS), and Referral Management System (RMS) Integrated Clinical Database-B (ICD-B) programs.
• Accurately refer patients to subsequent care using the most current MTF Capabilities Report, and the Access to Care (ATC) standards and RMC Business Rules as outlined in Air Force Instruction AFI44-176 and in the AFMS Referral Management Center Guide version 9.0, Attachment 1 of the PWS.
• Initiate, follow, manage, and close all referrals within timeliness standards identified in the TRICARE Operations Manual, the RMC business rules, and other current Government policies, regulations, and memorandums.
• Provide patient education including, but not limited to, specialty care referral, procedures, and labs to prepare the patient for their specialty care appointment and/or procedure.
• Provide MTF clinical personnel education concerning referral process and timelines, no less than semi-annually. The Contractor will utilize education opportunities during training venues to include, but not limited to, provider/nurse orientation briefings and Professional Staff (ProStaff) meetings.
• Identify and notify the Government MTF case manager, Utilization Management (UM) nurse or Primary Care Management (PCM) team, as appropriate, of any patient that may benefit from or may require care management/coordination.
• Sustain and follow the most current MTF Specialty Clinic Booking Guidance, MTF Capabilities Report and MTF/MCSC Memorandums of Understanding. Utilize these to maximize recapture initiatives and enhancements.
• Participate in inspections, by providing any requested referral management information by inspectors.

Referral Review/Appointing Function :

• Review initial specialty care and deferred-to network primary care referrals for administrative completeness (e.g., TRICARE Operations Manual, Chapter 8, Section 5), covered TRICARE benefit and required tests and pre-work. Coordinate with referring providers in cases where additional referral information is required.
• Verify patients are registered in CHCS and Defense Enrollment Eligibility Reporting System (DEERS); update demographic and other pertinent information through the appropriate medical systems and software programs. Obtain current and accurate contact information (i.e., cell/home phone numbers, and address).
• Determine patient eligibility for services and schedule specialty referral appointments to MTF or Other Direct Care System (ODCS) (ex: other nearby MTF) using CHCS booking procedures, ATC standards, and established clinic capability/ booking protocols as outlined in AFI 44-176 and in the AFMS Referral Management Guide. If there are no MTF or ODCS referral appointments within ATC standards, the RMC shall defer the referral to the network through the MCSC. The RMC shall transmit the referral though the RMS to the MCSC.
• Assist with ROFR determinations for specialty care that can be provided within the MTF using service availability (capability) listings and information systems that link the referral to the appointment with the ATC category and standard.
• Document patient appointments in the approved AFMS system(s), such as but not limited to CHCS, the RMS, and ALTHA. Enter ROFR-type referrals into CHCS for review and appointments.
• Process ROFRs within the time limits outlined in the TRICARE Operations Manual, Chapter 8, Section 5 (or as amended).
• Accept/decline urgent priority ROFRs and outside referral requests received within thirty (30) minutes of receipt.
• Accept/decline routine priority ROFRs and outside referral requests received within one (1) business day of receipt.
• Return completed referrals submitted by network/VA provider's specialty care referral results (ROFR results) to the referring purchased care provider within ten (10) business days of the kept specialty encounter.
• Verify that referrals are activated within the referral priority standards (Routine, Emergent, and Urgent). RMC staff shall assist with appointing/activating referrals and providing customer support to patients as outlined in the latest AFMS RMC Business Rules.
• Correct inaccurate authorizations in the RMS.
• Coordinate with specialty referral clinics (e.g., internal MTF, ODCS, Veteran's Affairs clinic, etc.) on special patient instructions and tests required prior to appointment.
• Provide pre-appointment instructions to patients, if possible, prior to leaving the MTF. Advise patients of the provider, location, time, and day of referral appointments or request the patient to call back for appointment information if patient not provided appointment prior to leaving the MTF. Include care episode information for the referral provider as to where to return referral results.
• Clinical Documents Requested by Purchased Care Providers. The referring provider/team will obtain additional medical information (e.g. lab reports, x-rays, previous encounter notes, etc.) to provide to the purchased care specialist as requested/ clinically required. The RMC can assist the PCM/team by faxing the documents to the specialist's office. For STAT/ASAP referrals, the ordering provider/team is responsible for obtaining and sending the requested information to the specialist.
• Contact and inform patients in the event referral requests are invalid (e.g., non- covered benefits) or disapproved by MTFs second level reviewer or MCSC. Reschedule or instruct patient of other health care options within two (2) business days of notification of referral being invalid or disapproved by the second level reviewer.
• Submit referrals to the appropriate reviewer when required for medical necessity and appropriateness review.
• Utilize the referral naming convention in Telephone Consults (T-Cons), AHLTA clinical notes and HAIMs, or additional systems, as outlined in the latest AFMS RMC business rules.
• Return all calls within two (2) business days.
• Monitor the secure messaging box three (3) times a day for messages. Follow- up with patients and/or direct messages to the PCM team accordingly.
• Generate and forward referral-related patient telephone consults requiring clinical decision-making to the appropriate provider/team.
• Review TRICARE Regional Office reconciliation/summary report daily; identify all open referrals and ensure resubmission.

Referral Tracking Function :

• Track and obtain initial specialty care and deferred to Network primary care