Referral Specialist

Purpose

This position's primary function is to process authorization requests timely and accurately in accordance with federal, state and accreditation guidelines. This position will be responsible for the completion of authorizations, including but not limited to, data entry of information received by phone, fax or electronically, verification of member eligibility, benefit coverage, coordination of benefits information, communication of the members' plan benefits and/or exclusions to with physician offices and collection of pertinent clinical documentation. The Referral Specialist works closely with the Care Coordinators and Case Managers to provide appropriate utilization of resources, timeliness of treatment and quality of care.. The Referral Specialist provides patient communication, pre-registration, supports scheduling appointments, and payment collection as necessary. The Referral Specialist does not make medical necessity determinations.

Nature And Scope

This position requires the highest standards of courteousness, performance, diplomacy and confidentiality for patients. The incumbent will work in a fast-paced environment that uses several modes of communication, including telephones, email, fax and instant messaging to respond to authorization inquires and new requests. This position has contact with other departments and health care providers and will act as a liaison between Hometown Health, Renown, health care providers, & health insurance carriers..This position will manage authorization requests.. The individual will gather, track and document all requests received by phone, fax, mail or electronically. This position will also manage oral and written communications related to the authorization, as appropriate. Additionally, this position is responsible for validating eligibility and benefit coverage to ensure the services requested are authorized as covered.This position is responsible for keeping the department leadership informed of customer opinions and viewpoints for continuous work process improvement.Knowledge, Skills & Abilities:1. Have a working knowledge of insurance products, including by not limited to HMO, PPO, Self-funded and Medicare Advantage Plans.2. Excellent written and verbal communication skills.3. Ability to process large amounts of information.4. Ability to work efficiently under stress and deadlines.5. Knowledge of medical terminology.6. Ability to assess a situation, consider alternatives and choose the appropriate course of action.7. Ability to work in a fast paced environment with constant interruptions.8. Manage multiple priorities and consistently meet department service and productivity goals.9. Knowledge regarding ICD-10and CPT code diagnosis and procedures with a high level of accuracy.10. Ability to organize and process work efficiently to ensure deadlines are met11. Have knowledge of HIPAA and/or The Joint Commission standardsUnder no circumstances shall Referral Specialist staff perform any activities related to the medical necessity review of the authorization management process other than:

• Performance of review of service request for completeness of information
• Collection and transfer of non-clinical data. Such data may include demographic information, employer name, insurance information, date of surgery, physician name, facility name, etc.
• Acquisition of structured clinical data in the form of medical records requests
• Activities that do not require evaluation or interpretation of clinical informationThis position does not provide patient care
  
  

Minimum Qualifications: Requirements - Required and/or Preferred Name Description Education: Ability to read, write, speak, and understand English sufficiently to perform job duties safely and effectively. High school graduation or GED. Experience: Requires at least one year of experience working in a medical office, hospital, health care billing or health insurance company. License(s): None Certification(s): None Computer / Typing: Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel, Teams, and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc. Disclaimer:

The foregoing description is not intended to be, and should not be construed as, an exhaustive list of all responsibilities, skills, efforts, or working conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.