SUMMARY

Provide consultation and administrative support for TRICARE beneficiaries. Ensure patient flow is optimized by assisting patients (CMHS Referral Management Team including the Central Referral Center- CRC and MTF Referral Management Centers) in processing referrals to specialty care.

ESSENTIAL DUTIES & RESPONSIBILITIES

• Review collected data to identify areas requiring intensive management. Analyze data collected and prepare reports describing resource utilization patterns. Disseminate information to government members of collaborative teams and multidisciplinary hospital committees.
• Coordinate specialty care referrals. Review specialty care referrals for appropriateness, completeness and route the referral to the appropriate place of care.
• Serve as a functional expert in the area of health benefits and provide health benefits advice to patients.
• Maintain and track referral records.
• Participate with referral centers in providing, assessing, and improving a wide variety of customer service and relations.
• Assist in the management of all forms of communication between beneficiaries, referral centers, internal staff and providers, network/outside providers and ancillary healthcare workers.
• Apply principles of utilization review (UR) and utilization management (UM) in processing specialty referrals.
• Plan and perform specialty referral reviews IAW established guidelines to provide quality cost-effective care.
• Conduct first level reviews for all referrals to specialty care.
• Act as a facilitator of professional and patient care activities.
• Interface with the Managed Care Support Contractor (MCSC)  and multidisciplinary personnel as needed to ensure appropriateness of referrals.
• Identify cases that may benefit from alternative levels of care and involve the case manager as needed to provide direction in care management.
• Plan and prioritize UR activities to ensure identified patient needs are addressed promptly.
• Effectively utilize information systems to develop, design, analyze, update and record data.
• Facilitate the development and integration of UM review policies and procedures into operations.
• Perform Right of First Refusal (ROFR) coordination of specialty care referrals.
• Maintain regular and punctual attendance.
• Perform other duties as assigned.

SUPERVISORY RESPONSIBILITIES

None.

MINIMUM QUALIFICATIONS

• High School Diploma or GED equivalency.
• Basic Life support certification (BLS) course completed by the American Heart Association or American Red Cross.
• Must have a minimum of three (3) years of clinical experience.
• Must have working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft Access, Microsoft Excel and Windows.
• Proficient in the current versions of office automation software relevant to the role.
• Knowledge of Professional Nursing Procedures.
• Working knowledge of EHR Genesis and MCSC databases.
• Must be able to read, understand, speak, and write English well enough to communicate effectively.
• Must obtain and maintain any necessary security access and/or background checks.

DESIRED QUALIFICATIONS & SKILLS

• Knowledge of medical terminology.
• ROFR knowledge in the area of health benefits.
• Knowledgeable in general medical ethics and health records administration.
• Excellent communication and customer service skills.

WORK SCHEDULE

Full-time. May be required to work additional hours as needed to complete assignment or project.

TRAVEL

None.

DRIVING REQUIREMENTS

None.

WORK ENVIRONMENT

Work is performed primarily in a professional office setting using standard office equipment such as computers, printers, and telecommunication devices. Employee will interact regularly with patients, healthcare providers, referral center staff, and multidisciplinary teams, requiring adaptability to a wide variety of personalities and functions.

PHYSICAL DEMANDS
Position involves sitting for extended periods, frequent use of hands and fingers for keyboard and mouse manipulation, occasional bending or stooping, and lifting up to 10 pounds. The role may require prolonged periods of phone or video communication. It is Katmai’s business philosophy and practice to provide reasonable accommodations, according to applicable state and federal laws, to all qualified individuals with physical or mental disabilities.

COMPENSATION & BENEFITS PACKAGE

• Pay: 22.16/hr
• H&W: $5.09
• Eligible Benefits: Medical, Dental, Vision, Life & AD&D Insurance, Long-Term & Short-Term Disability Insurance, 401(k) Savings Plan, Employee Assistance Program (EAP), Vacation & Paid Personal Time, 11 Paid Federal Holidays, and Leave of Absence.

Compliance:

To be considered for this position, all applicants must apply on the company website,  https://katmaicorp.com/life-at-katmai/

We are a VEVRAA Federal Contractor

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity or national origin, disability status, protected veteran status, marital status, familial status or any other characteristic protected by law. https://katmaicorp.com/life-at-katmai/#equal_opportunity Preference will be given to Ouzinkie Shareholders, Descendants of Shareholders and Spouses of Shareholders in accordance with Title 43 U.S. Code 1626(g) and Title 42 U.S. Code 2000e - 2(i).