Health Plan Referral Specialist - HP Utilization Management

Summary:

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

Responsibilities:

• Meets expectations of the applicable One CHRISTUS 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 maintains accurate tracking of services.
• Request and print various system report 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 turn around 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:

5 Days - 8 Hours

Work Type:

Full Time