Referral and Authorization Representative

SEIU Pay Range: $25.29 to $37.96 dependent on experience.

About the role

The Referral and Authorization Representative coordinates and facilitates the process of internal and external referrals and authorizations for CMH. This role responds to and processes standard and complex referral and authorization requests. Processing includes verifying eligibility, medical necessity, procedure and diagnosis coding, and patient benefit information. The position is accountable for efficient follow-through on all aspects of this process, including communicating with patients, working authorization denials, and creating appeals. Additionally, this role holds expert-level knowledge of daily workflows, consistently identifies areas for improvement, and demonstrates CMH CARES values.

Responsibilities

• Process standard and complex referral and authorization requests
• Verify eligibility, medical necessity, procedure and diagnosis coding, and patient benefit information
• Communicate with patients regarding referrals and authorizations
• Handle authorization denials and create appeals
• Identify areas of improvement in daily workflows
• Demonstrate CMH CARES values in all interactions

Requirements

• Knowledge of medical group or hospital operations
• Knowledge of medical terminology, procedural, and diagnosis coding
• Ability to prioritize duties, perform them efficiently, and adjust to unexpected changes
• Excellent spelling and grammar
• Strong telephone manners and etiquette
• Strong analytical, organizational, and time management skills
• Knowledge of various insurance plans such as Medicaid, Medicare, Commercial, Worker’s Compensation, and auto
• Experience using electronic medical records
• Ability to complete assigned projects and meet deadlines
• Knowledge of the cultural and social backgrounds of diverse patient populations
• One year of experience in a medical office setting
• Experience using medical terminology, CPT, and ICD-10 coding (preferred)
• Experience with authorizations and/or referrals (preferred)
• Proficiency with PC-based computer operations
• Detail-oriented with excellent organizational skills

Physical Demands and Work Environment

• Position involves standing, walking, stooping, and occasional carrying and lifting of lightweight materials (up to 20 pounds)
• May require sitting for extended periods of time
• Requires visual acuity and depth perception to recognize words and numbers
• Requires hand and finger dexterity and hand/eye coordination to use a computer keyboard and common office equipment