JOB DUTIES:
The Referral Coordinator position is responsible for performing reviewing and authorizing telephone, fax and mailed referral services requests for Durable Medical Equipment/supplies (DME), Prosthetics and Orthotics (P&O) and non-emergent transportation using pre-defined criteria. The Referral Coordinator also monitors out-of-plan physician visits and assists with selection of in plan providers. Additionally:
- Process healthcare service referral requests and all pertinent information from physician's/physician office staff, hospital discharge planners, case managers and other medical/clinical staff.
- Cross-references data to insure accuracy, completeness of information and appropriateness of referral as to benefits status and practitioner, provider and/or vendor participation.
- Reviews referral requests with attention to diagnosis, proposed length of service, eligibility, benefit coverage, supply/equipment utilization history if applicable, and applicable TWPMC policies.
- Data entry of patient demographic and health information into the AMISYS Management Information System for all referral service requests as required. May also enter information into other Health Services Management databases as required for reporting purposes.
- Respond to and resolve problems related to referral service requests, keeping the service requestor, Care Manager and other relevant parties informed of on-going status and resolution.
- Instructs patients having on-going service of procedures to obtain additional monthly supplies and necessary equipment service/repair from the supply provider or vendor, interceding when needed.
- Collaborates in reviewing practitioner/provider/vendor claims problems when requested by TWPMC Claims, Customer Services and Provider Contracting and Relations staffs regarding authorized services.
- Assists in providing written and verbal communication to physician's/physician's office staff, hospital discharge planners, case managers and other medical/clinical staff regarding members' order status, proper referral and authorization acquisition processes.
- Knowledge of medical terminology and ICD-9-CM, CPT and HCPCS coding experience.
- Demonstrate outstanding organizational and problem-solving skills with acuity for systemic thinking.
- Demonstrate excellent communication skills, both written and verbal.
- Ability to work independently and effectively organizes complex work processes.
- Ensures that The Wellness Plan is in compliance with privacy and security regulatory requirements of the federal Health Insurance Portability and Accountability Act (HIPAA).
- Excellent telephone etiquette and interpersonal skills
- Perform other duties as needed and/or assigned
MINIMAL REQUIREMENTS:
Formal education required: Associates Degree or in lieu of degree; High school graduate with minimum of 2- years referral, pre-certification or claims experience in a managed health care setting
Further formal education which is not required but which may be desirable: Graduate of Medical Assistant program or Associate degree
Additional knowledge, skills and abilities which are not required but which may be desirable: Experience with AMISYS or other managed care software. Experience in a healthcare claims, or billing department. Experience working in a federally qualified health center or community health center. Experience working for a FQHC.
Computer Skills: Word, Outlook, Excel, PowerPoint and web navigation skills.
