Clinical Referral and Authorization Navigator

Position Summary

This position is responsible for performing duties associated with patients being referred by their Hamilton Community Health Network primary care physicians to specialists or institutions for additional health care. Employee understands that employment is contingent upon adherence to HCHN policies and procedures, the mission of the organization, Joint Commission requirements and procedures, OSHA standards, and all other safety and health codes and laws.

Duties & Responsibilities

• Performs duties to execute the scheduling of complex procedures and timely resolution of patient referrals, including those that require authorization and/or pre-certification from payors.
• Ensures referrals that are made for patients are prepared for processing withing 24 hours of receipt from the provider.
• Researches the patient's insurance plan(s) to ensure that the referral is made to the proper provider within the patient's network.
• Responsible for following the guidelines as determined by each managed care plan specific to their referral process and for obtaining the appropriate authorizations. This includes:
  • Obtaining appropriate demographic identification for each managed care plan utilizing specific forms/data entry as specified.
  • Securing authorization and/or pre-certification using patient diagnosis and other required data by the payor.
  • Ensuring that patient information, such as current medication and problem lists, applicable labs, etc., are sent to the specialist office and/or payor for review.
• Responsible for transmission of appropriate authorization forms for referrals prior to the patient's appointment time.
• Fax or communicate appropriate records and authorizations to appropriate people for the completion of the referral process required by managed care providers.
• Schedule the patient for the necessary tests/procedures as ordered by primary care providers.
• Supply patient with the appropriate appointment instructions prior to test/procedure date of service.
• Regularly responsible for maintaining and updating provider and clinic staff with updates using the electronic medical records (EMR) and referral tracking system.
• Documenting specialist appointment status and attempts to secure consult documentation and/or need for additional appointments in EMR.
• Attend seminars or training sessions as appropriate for new managed care programs and/or for updates on existing programs.
• Maintain up-to-date information of referral guidelines, active providers, necessary coverage information, and private insurance requirements necessary for pre-certification or outside referral as well as other related information.
• Serve as a resource to answer questions from HCHN patients requesting referral assistance and/or from referring physicians to ensure accurate and efficient patient referral updates.
• Works collaboratively with providers at each site to identify concerns regarding timely completion of referrals and/or authorizations.
• Functions as the liaison with referral sources, managed care representatives, patients and providers concerning the network of care overseen by primary care providers at HCHN.
• Professionally handles patient complaints.
• Other duties as assigned.

Education and/or Experience

REQUIRED:

• High School Diploma and advanced coursework in clinical training from an accredited medical assistance program.
• Proven knowledge of Medicaid and managed care insurance programs.

OR

• Equivalent combination of education and experience requirements sufficient to successfully perform the duties of the job as listed above.

PREFERRED:

• Previous experience working with a managed care referral process.
• Nursing degree from an accredited school of nursing preferred.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• Ability to maintain confidentiality in all matters.
• Ability to provide excellent customer service skills.
• Ability to use the telephone and computer.
• Ability to work with the public.
• Ability to meet all attendance and punctuality requirements to ensure proper coverage and quality service.
• Ability to resolve interpersonal and professional conflicts appropriately.
• Professional and appropriate dress as required by the position.
• General computer proficiency.
• Takes pride in job performance as evident in compliance with job responsibilities.
• Assumes responsibility for work performance and is able to be self-directed.
• Participate in staff meetings, trainings and committees.
• Ability to travel from site to site whenever necessary.

Language Skills

• Ability to communicate effectively with diverse populations.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• While performing the duties of this job, the employee is regularly required to talk or hear.
• The employee frequently is required to stand, walk, sit; use hands to handle or feel; reach with hands and arms; and stoop, kneel, or crouch.
• The employee must occasionally lift and/or move up to 25 pounds.
• Specific vision requirements include the ability to see at close range.
• Fine hand manipulation (keyboarding).

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• Workspace located in clinical environment.
• May be exposed to communicable diseases.
• The noise level in the work environment is usually moderate.