Job Details

Client Job Description:

Processes referral requests for patients to ensure timely, accurate determinations. Works within the scope of practice to complete or forward requests as appropriate to Managed Care physicians and/or nurses as per the Utilization Management (UM) protocols. Maintains required turnaround times for referral completion. Assists providers and patients with questions about referral status. Participates in developing and implementing improvements to the referral process and workflows.

These Principal Accountabilities, Requirements, and Qualifications are not exhaustive but merely describe the current job. Management reserves the right to revise the job description or require other tasks when circumstances change (for example, emergencies, staff changes, workload, or technical developments).

JOB ACCOUNTABILITIES:

Processes referrals per standard work and refers others to nurses and/or MDs as necessary.

Maintains accuracy with attention to detail in each referral.

Monitors daily “pending” referrals to ensure timeliness standards are met and customer service is maximized.

Reports anticipated problems to the supervisor and/or other stakeholders.

Documents updated status in referrals per standard work.

Provides necessary medical information to obtain final determinations when required.

Processes referrals per health plan contracts and requirements.

Documents determinations in referral as per standard work.

EDUCATION: HS Diploma or equivalent education/experience

SKILLS AND KNOWLEDGE: Medical terminology, Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS)/International Classification of Diseases (ICD)-9 coding knowledge. Competency in using MS Office Excel and Word, and other Managed Care programs. Ability to identify, understand, and solve problems related to claims and referrals. Communication skills, including an understanding of medical concepts, the ability to organize thoughts, and the ability to communicate issues concisely and effectively. Proven ability to quickly adjust to changing projects and priorities and to multitask. Organizational skills.