Where compassion meets innovation and technology and our employees are family.
Thank you for your interest in joining our team! Please review the job information below.
GENERAL PURPOSE OF JOB:
Reports to the Central Patient Access Supervisor and serves as a primary point of contact for high-volume inbound calls and referral/authorization requests from physician offices and internal departments. Processes internal and
external referrals by obtaining and submitting medical records, verifying eligibility, securing benefit coverage determinations, guiding network steerage, and resolving referral issues. Work is primarily telephonic, computer-based, and office-based, and directly supports timely, appropriate patient care and health promotion by ensuring accurate, payer-compliant authorizations.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or hospital administration as required.
• Receives and documents, telephonic, and electronic requests for referrals from Primary Care Physicians, Specialists and Ancillary providers
• Contacts review organizations and insurance companies to obtain prior approval requirements and submit appropriate documentation.
• Verifies member eligibility and basic benefit coverage levels including obtaining information on coordination of benefits and third-party liability as appropriate.
• Maintains a current working knowledge of all Health Plan carrier requirements for referral request authorizations and approval path requirements. (Pre-Determinations and Peer to Peers)
• Investigates and obtains from providers, missing medical information required for referral submission.
• Utilizes computer resources to determine provider networks.
• Per referral guidelines evaluates each referral request to ensure the referral request including codes, place of service, service type, provider and all required medical information is available for submission to insurance carriers.
• Applies knowledge and application of ICD-9 and CPT coding, as well as medical terminology for appropriate communication with physicians and providers
• Performs data entry/processing of referral requests through the EPIC system, and edits referral notes with appropriate information as outlined per department procedures.
• Adheres to hospital policies and procedures.
• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
• Adheres and comply with customer service standards and dress code as set forth by the hospital and the department.
• Understand and apply payer rules to include commercial, Medicaid/CHIP, Medicare; OON vs INN rules; pre-auth vs pre-cert vs notification.
• CPT/HCPCS, ICD-10-CM, modifiers (incl. therapy, radiology, surgical bundles), NCD/LCD & payer medical-necessity criteria.
• Site-of-service & modality requirements (OP hospital, ASC, free-standing, telehealth).
• Coordination points: clinic workflows, surgery scheduling, imaging, pharmacy/infusion, DME, rehab, SLP/PT/OT.
• Privacy & compliance: HIPAA, minimum necessary, consent and minor/guardian nuances.
• EHR/PM and clearinghouse fundamentals; payer portals (Availity, UHC, BCBS portals, TMHP, etc.).
• Other duties as assigned
• Functions as a resource to physician/provider offices regarding steerage, referral process questions and education on Health Plan authorization submission requirements.
• Provides source of referral and prior approval requests with timely notification of approval or denial decisions through designated…