Central Insurance Referral Specialist II

UPMC•Lemoyne, PA

About The Position

This position plays a key role in coordinating the referral process across our outpatient sites, ensuring patients receive timely access to specialty care and diagnostic testing. This position manages specialty referrals, processes insurance authorizations, and completes pre‑certifications for diagnostic testing based on insurance requirements. It also involves educating patients about referral procedures, insurance benefits, and related policies while maintaining friendly, professional communication with patients, providers, and insurance companies. The role requires performing essential administrative tasks such as sorting printed documents and faxes, mailing letters, and submitting HMO referrals. We are looking for someone dependable, organized, and efficient to continue supporting our outpatient operations.

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 unbreached 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.