Referral Coordinator

Location: 
MMF-Medical Foundation
Schedule: 
Full Time
Shift: 
Day Job
Job Listing: 
MEM003706
Managed-Care

Job Summary   

Creates and assists with the preparation of referral requests.As part of the preparation process will verify eligibility, benefits, request any needed clinical notes and accurately complete or forward referral to appropriate staff to finalize decision. Ensures that all referral policies and procedures are followed as required to meet all contractual, regulatory and federal requirements

Essential Job Outcomes
  • Eligibility and benefits verification via website or telephone.Accurately and clearly documents information within the referral.
  • Assist in verifying accuracy of member address prior to completing the authorization.
  • Assure authorizations and member verbal notifications on urgent determinations are completed to meet current regulatory requirements as well as any additional required written notification requirements.
  • Consistently follow department processes for the following: Referral authorization- inpatient, outpatient, Urgent, Emergent, Routine referrals and FFS as assigned.
  • Run daily reports to capture all incoming referrals from the Portal, Electronic Medical Record, PCP, Specialists and account for Emergent/Urgent, ASA (auto status approval) referral and/or ODAG reports and other requested ad hoc reports for utilization, productivity and operational metrics.
  • Demonstrate the ability to explain managed care principles to others, i.e. contracted, non-contracted, full risk, shared risk, in-network, out-of-network, etc.
  • Correct authorizations that were incorrectly entered into the referral system.
  • Maintain 100% compliance in patient/employee confidentiality, as well as HIPAA compliance.
  • Request any clinical notes needed for reviewers.
  • Attach pertinent clinical criteria when needed and ensuredocuments are accurately labeled in referral system
  • Ensure scanned faxes and clinical notes are attached to the correct referral.
  • Accurately approve referrals meeting benefit criteria.
  • Demonstrates the ability to competently utilize the computer system and software for processing referrals
  • Demonstrate knowledge of Medical Terminology in order to respond to inquiries and be able to accurately translate and communicate complex information from the Health Plans, Case Management Nurses, Patients, Staff and vendors.
  • Answer telephone inquiries from physicians, staff and patients accurately and timely
  • Accurately approve referrals that fall within their scope of practice as determined by the medical management department.
  • Serve as resource for other departments, i.e. claims, network, customer service
  • Perform other duties as assigned by Management team
Qualifications: 

Experience

  • Experience in Managed Care or Medical Field 1-2 years preferred. Familiarity with the interpretation of health plan benefit manuals and CPT/ICD coding, preferred.
  • Type with speed and accuracy, 40 - 50 wpm.
  • Must have excellent computer skills.
  • Excellent customer service skills and be a team player.
  • Must be dependable.
  • High degree of organizational skills.

Education

  • Must be a High School Graduate/ or G.E.D or equivalent.
  • Medical terminology, preferred
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