Referral Management Reviewers (Bethesda, MD)

Duties and Responsibilities

• Perform referral review duties, seeking guidance from the product line nurse(s), and other members of the healthcare team and MTF points of contact as necessary.
• Reviews all referrals for administrative, clinical completeness and appropriateness, dispositioning the referral within 24 hours from the date referral was written.
• Collaborates with appointing center, case managers, product line nurses, providers, clinics, manage care support contractor liaison and other members of the healthcare team as needed to ensure proper use of Direct Care system and civilian network resources, as well as to ensure that patients are booked at the right time, with the right provider, at the right place.
• Completes and returns Clear Legible Reports (CLR) to the ordering civilian provider within the required ROFR timelines.
• Receives and places telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitors and processes referral management Genesis Work Lists to ensure consults are being processed within the established guidelines.
• Advises patients of their referral status. This may include providing references for benefit counseling assistance and/or patient advocacy. Reschedule/instruct patients of other health care options within 3 days of notification of disapproved referral or invalid referral. Advises of Line-of-Duty issues as it relates to referral management.
• Receives and enters ROFR referrals in MHS-GENESIS from the MCSC's portal for assigned specialties/product lines. Adheres to the defined timelines for response established by MHS, IRMAC standard operating procedures. Identifies and resolves ROFR issues in accordance with NCR Business Rules. Reports concerns related to the ROFR referral process to team lead as needed.
• Completes and returns Clear Legible Reports (CLR) to the ordering civilian provider within the required ROFR timelines.
• Verifies patients' eligibility in MHS-GENESIS. Update demographic information when needed.
• Documents in MHS-GENESIS, explaining appropriate options to patients when they refuse appointments within access to care (i.e., point of service, Tricare Select, be connected to Beneficiary Counselor and Assistance Coordinator).
• Contact product line nurse/clinic when appropriate for accommodation of highly valuable cases.
• Interfaces with the MCSC and multidisciplinary personnel as needed to ensure appropriateness of referrals. Submits referrals to non-network providers to TRICARE Service Center for medical necessity/appropriateness review.
• Routinely monitors referral management voicemail to ensure patient calls are returned within the guidelines established.
• Provides information about EPRO to requestors outside the NCR requesting care within the NCRC.
• Closes unused referrals as directed by DHA IPM, NCR MD policies and notifies ordering provider accordingly.
• Orients and trains new IRMAC staff in the referral processes and timelines.

Requirements

• A minimum of an Associate's Degree and a minimum of 2 years of experience in Utilization Management, Referral Management, Authorization/Denials, or Medical Claims Processing/Insurance Referral.
• Be a U.S. Citizen.
• Have the knowledge, skills, and computer literacy to interpret and apply medical care criteria, such as InterQual, Milliman Ambulatory Care Guidelines, Specialty Referral Guidelines (SRGs) or other evidence-based guidelines identified by the Military Health System (MHS).
• Have knowledge of medical terminology with an ability to learn MHS, VA-DOD Sharing Program, TRICARE, HIPAA, release of medical information.
• Have effective communication and people skills.
• Have demonstrated ability to provide superior customer service skills.
• Have demonstrated knowledge and understanding of Access to Care Standards within the Direct Care System.
• Be able to pay strict attention to detail and the appropriate use of deferral codes.
• Have excellent organizational skills, i.e., ability to manage time effectively, prioritize tasks, set goals, and implement plans for achieving those goals.
• Have a working knowledge of Microsoft Suite of Products, including Word, Excel, PowerPoint, Access, Outlook (email), and the Internet.

Benefits

• Medical, dental and vision coverage.
• Lifetime life and accidental death and dismemberment insurance.
• Short- and Long-Term Disability coverage.
• Supplemental Life insurance.
• A 401(k) Plan.