Referral Coordinator

About the role

Responsible for initiating and completing internal/external referral requests received through phone, fax, Health Connect, and online affiliate link. Initiates and completes data entry using a standardized documentation template and established policies and procedures. Provides initial review of benefits and eligibility for services requiring authorization. Assigns or ensures correct ICD-10, HCPCS, and CPT codes have been entered. Notifies members regarding referral/authorization orders, eligibility/benefit questions, and schedules appointments for external referral consultations, tests, and/or procedures. Supports the daily activities of the QRM/Post-Acute Regional Review Team.

Responsibilities

• Initiate and complete internal/external pre-certification referral requests.
• Perform data entry on all authorization requests using a standardized documentation template and established policies and procedures for clinical review.
• Enter and approve pre-certification notification-only requests (no clinical review) using established criteria and guidelines, documenting according to standard templates and policies.
• Review member eligibility and benefits using established criteria and guidelines; coordinate with member services and benefits department.
• Assign appropriate diagnosis and procedure codes following coding guidelines for ICD-10, CPT, and HCPCS for all pre-certification referral requests.
• Aid specialists, primary care practitioners, and office staff on coding and targeted review questions.
• Maintain current knowledge of coding and targeted review items to ensure correct routing per contract and benefit guidelines and adhere to Kaiser Permanente time frames (routine, expedite, urgent, state, and federal).
• Ensure coding is completed correctly on all requests to meet regulatory guidelines and audit standards for compliance and correct reimbursement.
• Send a copy of the referral form to the consultant via member or fax after data entry completion.
• Assist and educate members by answering questions about the referral and authorization process.
• Assist and educate external consultants with questions and concerns regarding the referral process in the medical office.
• Maintain effective interaction and communication with physicians and their staff to gather referral information as needed.
• Support operational activities for the QRM review team and assist referral leadership with report preparation and other duties as assigned.
• Forward authorization requests (live caller or documented record) requiring clinical review to the appropriate review staff/team.
• Provide verbal notification according to policy and procedure for members and providers regarding the outcome of their requested service.
• Provide members with information about consultant office location, address, and phone number.
• Manage incoming Right Fax physician requests by sorting, entering into the authorization system, and assigning to the correct specialty reviewer.
• Remain knowledgeable of contract benefits, eligibility guidelines, and current state and federal regulations affecting managed care and utilization management.
• Interact with physicians, staff, and team members to gather required information for clinical reviews.
• Maintain excellent customer service and professionalism with providers, members, and team members.
• Meet department productivity standards and ensure accuracy in data entry.
• Maintain effective interaction and working relationships with medical staff, complex case managers, regional review RNs, and other QRM staff to facilitate the review process.
• Work cross-functionally with other departments such as Kaiser Permanente Medical Offices, Customer Services, Claims, Provider Relations, Appeals, and Risk Management to meet organizational goals.
• Investigate, identify, and report problems and inefficiencies in existing systems; recommend changes to referral leadership when appropriate.
• Comply with regional and QRM department-specific personnel policies and procedures.
• Develop and maintain awareness of how to report compliance issues and concerns.
• Identify the need for social services intervention and refer members to KP social workers as appropriate.
• Maintain complete and accurate data entry for all internal/external pre-certification referrals into Epic Tapestry based on policies and procedures.

Requirements

• Minimum four (4) years of healthcare industry or relevant business experience.
• Minimum six (6) months of experience receiving and processing referral requests or other data entry experience.
• High School Diploma or General Education Development (GED).

Qualifications

• Certified Coding Specialist within 6 months of hire OR Certified Coding Specialist - Physician Based within 6 months of hire OR Certified Professional Coder within 6 months of hire OR Certified Outpatient Coder within 6 months of hire.

Preferred Qualifications

• Epic Tapestry experience preferred.
• Minimum one (1) year of experience with CPT and ICD-10 coding knowledge preferred.
• Medical Terminology Certificate preferred.