The Referral Specialist will manage requests for incoming/outgoing referrals and medication prior authorization. The Referral Specialist will provide information, problem solve, and coordinate efforts regarding Referrals and medication authorizations. The Referral Specialist will provide quality customer service to our patients, providers, co-workers and insurance companies by providing timely and accurate information.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
Strives to achieve excellence in service.
Verifies correct patient using 2 identifiers.
Processes referrals ordered by providers.
Coordinates referrals for medical appointments and procedures; face to face whenever possible.
Advise patient of referral guidelines, options and process based on insurance coverage.
Verifies insurance coverage and obtains authorization if needed from insurance coverage.
Communicates with members of the treatment team, as needed.
Coordinates necessary services needed (i.e. transportation, medical records, radiology reports, and other pertinent information to the appropriate place of service).
Processes work comp requests.
Provide information based on payer criteria.
Manages medication prior authorizations, including denials and appeals.
Acts as a resource and a liaison to health care plan participants and providers for problem solving, trouble shooting and general information.
Utilize customer service skills in order to positively impact the experience of care for our patients, external customers and internal service partners.
Develops and maintains cooperative customer service to both internal and external customers.
Prioritizes multiple work tasks, operates office equipment, including computers and peripherals.
Adheres to HIPAA, Privacy Standards, and Confidentiality Agreement.
Attend workshops to improve knowledge.
Participate in various task forces and committee projects, as assigned.
Supports the policies and procedures of the organization and the standards of the Joint Commission as required for full accreditation.
Works to understand and value diversity of others.
Considers age-related factors when dealing with patients ranging from neonates, pediatrics, adolescents, adults and geriatrics. Applies knowledge of age-related factors appropriately in accordance with professional standards and departmental policies and procedures.
Other duties as assigned.
This job has no supervisory responsibilities.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE
Associate degree/diploma/certification in related field. Proficient in Medical Terminology. Prior authorization experience preferred.
Working knowledge of current word processing and graphics software (Windows environment which may include: Word, Excel, Outlook, and PowerPoint). Proficient in Excellian and Meditec. Excellent typing skills, communication, and phone skills.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is frequently required to sit. The employee is occasionally required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms; stoop, kneel, crouch, or crawl; and talk or hear. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception, and ability to adjust focus.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is occasionally exposed to fumes or airborne particles and toxic or caustic chemicals. The noise level in the work environment is usually moderate.
Performs a Class III job as classified by OSHA and may be exposed to Class III hazards.