Referral Care Specialist

Position Purpose

This position's primary function is to process authorization requests timely and accurately in accordance with federal, state and accreditation guidelines. This position will be responsible for the completion of authorizations, including but not limited to, data entry of information received by phone, fax or electronically, verification of member eligibility, benefit coverage, coordination of benefits information, communication of the members' plan benefits and/or exclusions to with physician offices and collection of pertinent clinical documentation. The Referral Specialist works closely with the Care Coordinators and Case Managers to provide appropriate utilization of resources, timeliness of treatment and quality of care.. The Referral Specialist provides patient communication, pre-registration, supports scheduling appointments, and payment collection as necessary. The Referral Specialist does not make medical necessity determinations.

Nature and Scope

This position requires the highest standards of courteousness, performance, diplomacy and confidentiality for patients. The incumbent will work in a fast-paced environment that uses several modes of communication, including telephones, email, fax and instant messaging to respond to authorization inquires and new requests. This position has contact with other departments and health care providers and will act as a liaison between Hometown Health, Renown, health care providers, & health insurance carriers..

This position will manage authorization requests.. The individual will gather, track and document all requests received by phone, fax, mail or electronically. This position will also manage oral and written communications related to the authorization, as appropriate. Additionally, this position is responsible for validating eligibility and benefit coverage to ensure the services requested are authorized as covered.

This position is responsible for keeping the department leadership informed of customer opinions and viewpoints for continuous work process improvement.

Knowledge, Skills & Abilities:

1. Have a working knowledge of insurance products, including by not limited to HMO, PPO, Self-funded and Medicare Advantage Plans.
2. Excellent written and verbal communication skills.
3. Ability to process large amounts of information.
4. Ability to work efficiently under stress and deadlines.
5. Knowledge of medical terminology.
6. Ability to assess a situation, consider alternatives and choose the appropriate course of action.
7. Ability to work in a fast paced environment with constant interruptions.
8. Manage multiple priorities and consistently meet department service and productivity goals.
9. Knowledge regarding ICD-10and CPT code diagnosis and procedures with a high level of accuracy.
10. Ability to organize and process work efficiently to ensure deadlines are met
11. Have knowledge of HIPAA and/or The Joint Commission standards

Under no circumstances shall Referral Specialist staff perform any activities related to the medical necessity review of the authorization management process other than:

• Performance of review of service request for completeness of information
• Collection and transfer of non-clinical data. Such data may include demographic information, employer name, insurance information, date of surgery, physician name, facility name, etc.
• Acquisition of structured clinical data in the form of medical records requests
• Activities that do not require evaluation or interpretation of clinical information

This position does not provide patient care.

Disclaimer

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Minimum Qualifications

Requirements - Required and/or Preferred Name

Description

Education:

High school graduation or GED. Must have a working-level knowledge of the English language, including reading, writing and speaking English.

Experience:

Requires at least one year of experience working in a medical office, hospital, health care billing or health insurance company.

License(s):

None

Certification(s):

None

Computer / Typing:

Must be proficient with Microsoft Office Suite, including Outlook, Excel and Word and have the skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.