Health Plan Referral Specialist

Health Plan Referral Specialist

Summary:
Processes all requests for referral authorizations and researches problem referral claims or requests for payment.

Responsibilities:

• Meets expectations of the applicable Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Expedite the flow of authorization requests through the Managed Care System.
• Prepare requests for authorization of services by ensuring form completion, eligibility, verification, chart availability, benefits etc.
• Accurately enter referral information into the computer system with a thorough understanding of the correct system codes (type, status, procedure etc.).
• Facilitate documentation of authorizations into the computer system.
• Notify patients and providers of authorization decisions and maintain accurate tracking of services.
• Request and print various system reports to perform daily tasks and to track referral-based activity for management reporting purposes.
• Utilize tracking system to monitor the flow of referrals through the authorization process and to allow for measurement of turnaround times and timely processing of referrals.
• Prepare requests for authorization of services by ensuring form completion, eligibility, verification, chart availability, benefits, etc.
• Notify all parties involved of authorization decisions to include patient, provider, requester, HMO, etc.
• Ensure appropriate actions have occurred such as scheduling of diagnostic appointments, requests for documentation/treatment plan etc.
• Distribute copies of referral to all appropriate sources (chart, provider, etc.) and accurately document activities associated with the referral in the medical file and computer system.
• Coordinate the initiation of specific home health services, DME services, diagnostics, etc., as directed by the nurse/physician for managed care plan members.
• Serve as a resource to staff and providers regarding managed care systems, HMO/PPO benefits, contracted providers, etc.
• Interface with HMO/PPO patients for direction through the referral process to increase an understanding of the authorization requirements mandated by the insurance plan.
• Promote and coordinate activities of payer agencies, groups or individuals to help provide answers and meet the needs of provider and/or patient.
• Assist in referral research for billing and collections process.
• Maintain contact with representatives of other organizations to exchange and update information on resources and services available.

Requirements:

Education/Skills

• High School diploma or equivalent required
• Associate's degree or higher in allied health professional field of study, preferred
• Working knowledge of medical terminology and CPT background, preferred
• Good typing skills
• Basic knowledge of computers
• Excellent customer service skills

Experience

• Minimum of two (2) years in related working environment such as hospital, physician office, or managed care organization, preferred

Licenses, Registrations, or Certifications

• None required

Work Schedule: 8AM – 5PM Monday–Friday
Work Type: Full Time

Job Types: Full-time, Contract

Pay: Up to $18.00 per hour

Expected hours: 40 per week

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Vision insurance

Education:

• High school or equivalent (Required)

Experience:

• Hospital, Physician Office : 2 years (Preferred)
• Health Plan Referral Specialist : 2 years (Required)
• Medical terminology: 2 years (Preferred)
• CPT background : 2 years (Preferred)

Ability to Commute:

• Irving, TX 75039 (Required)

Work Location: In person

Salary : $18