Referral 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 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 inquiries and new requests. This position has contact with other departments and healthcare providers and will act as a liaison between Hometown Health, Renown, healthcare providers, and 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
Have a working knowledge of insurance products, including but not limited to HMO, PPO, self-funded, and Medicare Advantage Plans.
Excellent written and verbal communication skills.
Ability to process large amounts of information.
Ability to work efficiently under stress and deadlines.
Knowledge of medical terminology.
Ability to assess a situation, consider alternatives, and choose the appropriate course of action.
Ability to work in a fast-paced environment with constant interruptions.
Manage multiple priorities and consistently meet department service and productivity goals.
Knowledge regarding ICD-10 and CPT codes with a high level of accuracy.
Ability to organize and process work efficiently to ensure deadlines are met.
Knowledge regarding HIPAA and/or The Joint Commission standards.
Other Responsibilities
Under no circumstances shall Referral Specialist staff perform any activities related to the medical necessity review of the authorization management process other than performing the review of service requests for completeness of information.
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.
Minimum Qualifications
Name: High school graduation or GED.
Description: Requires at least one year of experience working in a medical office, hospital, health care billing, or health insurance company.
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.