Central Insurance Referral Specialist II - UPMC Central Referrals

UPMC•Hanover, PA

4d•Onsite

About The Position

The Insurance Specialist II coordinates referrals and authorizations across outpatient practices. Responsibilities include managing specialty referrals, coordinating diagnostic testing, obtaining insurance referrals and prior authorizations, and securing pre-certifications required by insurance carriers. The role educates patients about referral requirements, insurance benefits, and practice policies to support an efficient care experience. As a liaison among patients, providers, specialty offices, and insurance companies, the specialist facilitates timely communication and coordination of care while maintaining a friendly, courteous, and professional approach. The role manages referrals and authorizations for more than three specialty areas across multiple geographic locations, requiring strong organization, attention to detail, and the ability to manage complex workflows in a fast-paced environment.

Requirements

High school graduate or equivalent.
At least 2 years of experience in a physician's office or outpatient facility.
Knowledge of Electronic Medical Records/Electronic Health Information systems.
Knowledge of insurance companies, guidelines and requirements, authorization and referral processes, and insurance websites.
Knowledge of medical terminology, anatomy, disease processes, CPT and ICD-9 coding, and managed care policies and procedures.
Familiarity with Windows software, Word, Excel, and Outlook.
Strong organizational and communication skills.
Ability to work independently and as part of a team.
Act 34 clearance.

Responsibilities

Interact with physicians, physician extenders, and fellow employees in a courteous and professional manner.
Explain policies and procedures clearly, answer questions, and provide age-appropriate instruction to patients and family members.
Be attentive to individual needs, receptive to questions and criticism, and willing to offer assistance.
Protect each person's legal and moral right to confidentiality.
Perform other duties as assigned by the manager.
Use electronic referral and authorization services when available.
Communicate with insurance offices to authorize services.
Accept referral requests from patients, specialists, and primary care offices.
Answer telephone calls in a timely, pleasant, and professional manner.
Handle appeal requests with insurance companies when necessary.
Coordinate out-of-network exceptions with insurance companies when necessary.
Provide necessary patient medical information to insurers upon request.
Obtain insurance authorizations for diagnostic testing.
Schedule appointments accurately, observing all scheduling criteria.
Transcribe Epic orders as indicated by the ordering provider.
Handle urgent and ASAP appointment requests promptly.
Maintain a referral log and document referrals in patient medical records.
Maintain an up-to-date listing of network providers.
Complete insurance referrals for patients' scheduled appointments.
Monitor referrals to help patients stay within network and coordinate with insurance to return patients to the network if they go out of network.
Coordinate diagnostic testing appointments, advise patients about test preparation when applicable, and obtain insurance authorization when applicable.
Send appointment requests to specialists with appropriate patient records and process insurance referrals when applicable.
Coordinate appointments with specialist offices inside and outside the local area.
Attend meetings and training sessions provided by insurers.
Handle patient inquiries about referrals and authorizations.
Maintain current referral and authorization guidelines and requirements from insurance companies.
Educate and assist providers in selecting diagnostic test orders accurately based on current radiology guidelines.
Educate members, providers, and office staff about insurance guidelines and requirements related to referrals and authorizations.