Referral Coordinator (Templeton, CA)

Responsibilities

• To be efficient in use of UM prior authorization systems utilized.
• Verify eligibility and benefit interpretation, via health plan and Medicare (CMS) websites.
• Be a resource for providers in regard to questions regarding network specialists.
• Ability to prepare authorizations and refer to appropriate providers/facilities and durable medical equipment (DME) companies.
• Guide and communicate with physician office, processing staff and other departments as needed to ensure collaboration and open discussion regarding all aspects of the referral process. Including responding to messages within the next business day.
• Review accuracy of pending referrals for ICD-10, CPT, HCPC code and provider selections made by the Authorization Clerk staff.
• Ensure referral data entry was accurately inputted into UM systems based on the referral and clinical information submitted.
• Have a complete understanding of established policy and procedure within Heritage provider network regarding the authorization processes.
• Maintaining assigned duties in an acceptable manner.
• Inform management on a daily basis when problems arise or when work falls behind.
• Compile and document good faith attempts in obtaining medical records for each pending referral when there is lack of information.
• Compile clinical based guidelines, criteria and/or benefit information prior to forwarding referral to UM Managers for clinical review.
• Maintain filing in a timely manner.
• Provide Referral Coordinator coverage as needed.
• Process referral published on daily trending reports to maintain compliance with health plans and CMS timeframe regulations.
• Follow and have a complete understanding of the health plan and CMS regulations regarding timelines standards, benefit, and guideline hierarchy.
• Adaptable to regulation and necessary departmental procedure changes that affect UM prior authorization processes.
• Compliance with HIPM regulations and maintain patient confidentiality.
• Cultural and Linguistics training required annually.

Requirements

• High School graduate or GED certification required.
• One-year minimum experience working in a medical office environment (IPA or HMO preferred) with prior authorizations required.
• Knowledge of medical terminology required.
• Knowledge of HCPC, CPT and ICD-10, required.
• Proficient written and oral communication skills.
• Demonstrate proficiency in computer systems utilized.
• Able to remain organized and able to manage competing priorities.
• Demonstrate good judgement.
• Demonstrate ability to take and follow through with delegated tasks and accountability.
• Demonstrate resourcefulness in problem-solving.

Qualifications

• None specified

Skills

• None specified

Benefits

• Not specified

Pay

The pay range for this position at commencement of employment is expected to be reasonably between $24.27 and $28.55. However, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, skills, and experience.

Schedule

Not specified