Referral Specialist

Job Summary

Ensures accuracy and completion of authorization data from customer information, medical records, referral/authorization forms, Military Treatment Facility electronic transmission and other documents into medical management system. Examine and evaluate document contents to ensure accuracy and to correct inconsistencies.

Duties

• Maintains confidentiality of TriWest beneficiaries' health information.
• Affirms tasks for authorization/referral request to ensure accurate entry into the medical management system.
• Identifies potential discrepancies in the medical management system to assure quality compliance.
• Consistently meets department productivity and performance metrics.
• Follows HIPAA compliance and TriWest confidentially guidelines.
• Refers beneficiaries to network providers.
• Solves issues to complete care request.
• Reads and comprehends diagnosis, procedures and requested service on incoming care requests.
• Aids in resolving data quality issues by identifying, documenting, and communicating quality issues.
• Resolves process issues to ensure high quality service levels throughout TriWest.
• Seeks advice and escalates issues or problems as warranted.
• Processes referrals for Behavioral Health, Specialty Care, Durable Medical Equipment, Inpatient Admissions, Military Treatment Facilities, and Urgent referral and authorization requests.
• Assesses electronic documents to ensure appropriate entry into the medical management system.
• Works with standard coding systems including: standard medical taxonomy, ICD-10, CPT and HCPCS codes.
• Verifies beneficiary eligibility and ensures appropriate referral procedures are followed for the various types of TRICARE beneficiaries.
• Ensures procedures are followed for referrals based on beneficiary eligibility type, geographical location, and on the provider's request.
• Processes authorization requests and referral requests in the on-line medical management system.
• Communicates with other departments, medical providers, and beneficiaries to clarify documentation prior to processing.

Competencies

• Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.
• Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.
• Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.
• Empathy / Customer Service: Customer-focused behavior; helping approach, including listening skills, patience, respect, and empathy for another's position.
• Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.
• Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
• Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.
• Technical Skills: Knowledge of TRICARE and the Military Health System programs; ability to use CHCS booking procedures, ATC standards and established clinic capability/booking protocols.

Working Conditions

• Ability to cover any work shift.
• Works within a standard office environment.
• Onsite: Works within a standard office environment.
• Remote: Private and secure workspace and workstation with high speed internet is required.
• Extensive computer work with prolonged sitting, wearing of headset, typing, speaking on a phone.

Company Overview

Taking Care of Our Nation’s Heroes. It’s Who We Are. It’s What We Do. Do you have a passion for serving those who served? Join the TriWest Healthcare Alliance Team! We’re On a Mission to Serve®! Our job is to make sure that America’s heroes get connected to health care in the community. At TriWest Healthcare Alliance, we’ve proudly been on that important mission since 1996.

DoD Statement

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Benefits

• Medical, Dental and Vision Coverage
• Paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time

Equal Employment Opportunity

We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.