Referral Specialist

About the role

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.

Responsibilities

• 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.
• Performs other duties as assigned.

Requirements

• U.S. Citizenship
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• High School Diploma or G.E.D.
• 1 + year experience in health care operations performing data entry or customer service
• Experience with Microsoft Office

Qualifications

• Preferred Referral and authorization processing experience
• Knowledge of medical terminology obtained through medical assistant certification or experience interpreting and applying ICD and CPT codes
• Managed Care experience
• TRICARE experience
• Veteran or military spouse or military affiliated

Skills

• Communication / People Skills
• Computer Literacy
• Coping / Flexibility
• Empathy / Customer Service
• Multi-Tasking / Time Management
• Organizational Skills
• Problem Solving / Analysis
• Technical Skills

Benefits

We’re more than just a health care company. We’re passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes:

• 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

Pay

$40,000 - $45,000 per year

Schedule

Regular and reliable attendance is required.