Central Insurance Referral Specialist II - Lemoyne

UPMC•Lemoyne, PA

1h•Onsite

About The Position

The Insurance Specialist II plays a vital role in coordinating the referral and authorization process across outpatient practices. This position is responsible for managing specialty referrals, coordinating diagnostic testing, obtaining insurance referrals and prior authorizations, and securing pre-certifications as required by insurance carriers. The Insurance Specialist II educates patients on referral requirements, insurance benefits, and practice policies to help ensure a smooth and efficient care experience. Serving as a key liaison between patients, providers, specialty offices, and insurance companies, this role facilitates timely communication and coordination of care while maintaining a friendly, courteous, and professional approach. The Insurance Specialist II manages referrals and authorizations for more than three specialty areas across multiple geographic locations, requiring strong organizational skills, attention to detail, and the ability to effectively manage complex workflows in a fast-paced environment.

Requirements

High school graduate or equivalent.
Minimum of 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 process and websites.
Knowledge of medical terminology, anatomy, disease processes, CPT and ICD-9 coding, and managed care policies and procedures.
Familiar with Windows software, Word and Excel and Outlook.
Must possess strong organization and communication skills and be able to work independently and within a team.
Act 34

Responsibilities

Interacts with physicians, physician extenders, and all fellow employees in a courteous and professional manner.
Clearly explaining all policies and procedures, answering questions, and providing instruction to patients and family members in an age specific manner.
Being aware of the individual's needs, receptive to questions and criticism, and willing to offer assistance.
Protecting each person's legal and moral right to unbreeched confidentiality.
Performs other duties as assigned by manager.
Utilizes electronic referral and authorization services as available.
Communicates with insurance offices to authorize services.
Takes referral requests from patient, specialist, and primary care office.
Answers telephone in a timely, pleasant, and professional manner.
Handles appeal requests with insurance company when necessary.
Coordinates out of network exceptions with insurance company when necessary.
Provides necessary patient medical information to insurance upon request.
Obtains authorizations with insurance companies for diagnostic testing.
Accurately schedules appointment with attention to all scheduling criteria.
Transcribes Epic orders as indicated by the ordering provider.
Handles Urgent and ASAP appointment requests in a timely fashion.
Maintains referral log.
Documents all referrals in patient medical record.
Maintains up-to-date listing of all network providers.
Completes insurance referrals for patient’s scheduled appointments.
Monitors referrals to ensure patients stay within network. If patient goes out of the network, coordinates with insurance to get patient back into network.
Coordinates appointments for diagnostic testing. Advises patient of test prep if applicable. Obtains insurance for authorization, if applicable.
Sends appointment request to specialist with appropriate patient records. Processes insurance referral if applicable.
Coordinates appointments with specialist's offices in and outside of the local area.
Attends meetings and training sessions provided by insurers.
Handles patient inquiries related to referrals and authorizations.
Maintains up to date referral and authorization guidelines and requirements from insurance companies.
Educates/assist providers on accurate diagnostic test order selection based on current radiology guidelines.
Educates members, providers, and office staff on the insurance guidelines and requirements, related to the referral and authorization process.