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Job Description
POSITION DESCRIPTION
This position is responsible for all aspects of the referral process, including authorizations and follow-up.
ESSENTIAL JOB FUNCTIONS
Contacts insurance companies via appropriate methods and obtains authorizations if applicable for specific plans. Educates patients and staff with pertinent referral and insurance information. Obtains urgent authorizations same day and next day, if needed. Assists patients in scheduling appointments with specialist and help resolve referral issues. Generates referral information for physicians, patients and health plans. Acts as a liaison among providers, patients and health plan administrators. Responsible for reviewing and submitting clinical information to health plan case managers for special referral pre-certification and out-of-plan or out-of-network referrals; monitors authorizations or denials and follows up, as necessary. Communicates referral status to patients and physicians; ensures that referrals have been processed accurately and in a timely manner to coincide with patient treatment plan. Answering incoming calls that are relevant to referrals. Outreach to patients when appropriate for details on appointments and/or insurance information. Verification of insurance through payor sites and notifying patients if there needs to be changes made prior to processing the referral. Test tracks the referrals until fulfilled by the patient. This would include outbound calls to patients and external specialists for updates. At times, may need to request external specialist office visit notes to be shared with the referring provider. Updates information in the patient medical record (EMR) with approval of declination of information; follows up with the primary care physician as to the status and/or issues with the referral authorization. Communicates with the ordering provider for next steps with practice support staff and representatives of insurance companies. Participates in data collection of insurance companies. Supports other offices, attends required meetings and training, and participates in committees, as requested. Assists with special projects and assumes additional duties as assigned.
ORGANIZATIONAL EXPECTATIONS
Creates a positive, professional, service-oriented work environment for staff, patients and family members by supporting the mission and values of Trinity Health Medical Group. Must be able to work effectively as a member of the Referral Coordinator team. Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management. Successfully completes all relevant organizational training and adheres to Trinity Health Medical Group standard of care as outlined in the Trinity Health Code of Conduct. Maintains knowledge of and complies with Trinity Health Medical Group standards, policies and procedures. Maintains general knowledge of Trinity Health Medical Group office services and in the use of all relevant office equipment, computer and manual systems. Maintains strict confidentiality in compliance with Trinity Health Medical Group and HIPAA guidelines. Serves as a role model by demonstrating exceptional ability and willingness to take on new and additional responsibilities. Embraces new ideas and respects cultural differences. Uses resources efficiently. If applicable, responsible for ongoing professional development - maintains appropriate licensure/certification and continuing education credentials, participates in available learning opportunities.
MEASURED BY
Performance that meets or exceeds
IHA CARES
Values expectation as outlined in IHA Performance Review document, relative to position.
ESSENTIAL QUALIFICATIONS
EDUCATION:
High School Diploma
CREDENTIALS/LICENSURE
None
MINIMUM EXPERIENCE
Minimum 2 years' experience with insurance referrals, prior authorization or other relevant medical office experience.
POSITION REQUIREMENTS
(ABILITIES & SKILLS): Knowledge of medical terminology and procedures at the level needed to perform responsibilities. Knowledge of the compliance aspects of clinical care and patient privacy and best practices in medical office operations. Proficient knowledge of major health plans and insurance processes. Excellent written (legible), verbal and face-to-face communication skills, including ability to effectively explain relevant insurance information to patients, as well as communicate with insurance plans and internal customers. Proper phone etiquette. Proficient/knowledgeable in patient care procedures and organizational policies related to position responsibilities. Service-oriented; responsive to customer needs and courteous in approach. Proficient in operating a standard desktop and Windows-based computer system, including but not limited to, electronic medical records, EPIC, Microsoft Word /Excel/Outlook, intranet and computer navigation. Ability to use other software as required while performing the essential functions of the job. Ability to compute mathematical calculations. Ability to work independently and collaboratively in a team-oriented environment; displays professional and friendly demeanor. Ability to work effectively with various levels of organizational members and diverse populations including IHA staff, patients, family members, vendors, outside customers and couriers. Ability to cross-train in other areas of practice in order to achieve smooth flow of all operations. Good organizational and time management skills to effectively juggle multiple priorities and time constraints. Ability to exercise sound judgement and problem-solving skills. Ability to handle patient and organizational information in a confidential manner. Ability to travel to other office/practice sites and meeting and training locations. Successful completion of IHA competency-based program within introductory and training period.
MINIMUM PHYSICAL EXPECTATIONS
Physical activity that often requires keyboarding, filing and phone work. Physical activity that often requires extensive time working on a computer. Physical activity that sometimes requires walking, standing, bending, stooping, reaching, and/or twisting. Physical activity that sometimes requires lifting, pushing and/or pulling under 30 lbs. Specific vision abilities required include close vision, depth perception, peripheral vision and the ability to adjust and focus. Manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment. Must hear and speak well enough to conduct business over the telephone or face to face for long periods of time in English.
MINIMUM ENVIRONMENTAL EXPECTATIONS
: This job operates in a typical office environment with some exposure to contagious diseases/viruses. It requires significant interaction with people (many of whom are scared, hurt and/or ill) which can be stressful and result in competing priorities.
